Get Bcbsm Hospice Facility Sig Doc

Filling out the BCBSM Hospice Facility Signature Document is an important step for providers seeking to participate in the BCBSM Hospice Provider Participation Agreement. This guide will walk you through the process of completing the form online with clarity and detail.

Follow the steps to complete the BCBSM Hospice Facility Sig Doc online

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the 'Provider/Facility Name' field with the official name of the facility applying for participation.
3. Enter the 'Provider’s Authorized Representative with Signature Authority.' This person is typically the individual who has the authority to sign on behalf of the facility.
4. Provide the signature of the 'Provider’s Authorized Representative' in the designated area to validate the agreement.
5. Input the 'Date' that you are filling out the form to document when the signature was affixed.
6. Complete the 'Primary Site Address' by inputting the street address where the facility is located.
7. Fill in 'City,' 'State,' and 'Zip Code' to provide the location details for the facility.
8. Enter the 'Tax Identification Number' in the corresponding field for tax purposes.
9. Provide the 'Tax ID Name' that the tax identification number is registered under.
10. Input the 'National Provider Identifier (NPI)' that has been assigned to your facility.
11. Fill out the 'Medicare Certification Number' necessary for the Medicare program.
12. Include the 'Facility License Number' given to your facility by state regulators.
13. Once all fields are completed, save your changes to ensure that all information is retained.
14. You may download, print, or share the finished form as needed, or return the completed Signature Document with your application form.

Complete the BCBSM Hospice Facility Signature Document online today and ensure your participation in the program.