Get Licsw Contracting Application - Blue Cross Blue Shield Of ...

This guide will provide users with a clear and supportive approach to completing the LICSW Contracting Application for Blue Cross Blue Shield. It is essential to ensure all sections are filled out accurately to facilitate the processing of your application.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the LICSW Contracting Application and open it in your chosen editor.
2. Begin with Section A, 'Individual Information'. Fill out your name, date of birth, Social Security number, Massachusetts LICSW license number, and National Provider Identifier (NPI). If applicable, also list other Massachusetts license numbers and professional societies you are a member of.
3. Complete Section B, 'Practice Information'. Indicate the total number of practices you have and their statuses. For each practice, provide the practice name, DBA (if applicable), NPI, address, and contact information.
4. Answer field B.4 regarding whether the practice is your primary address and B.5 if it is your home address. Check the relevant boxes and provide any necessary explanations.
5. Continue with questions in Section B regarding after-hours coverage, appointment availability, and additional practice locations. Ensure you provide accurate details for each question.
6. Proceed to Section C, 'Document Request'. Ensure all requested documents, such as W-9 forms and reference letters, are completed and attached.
7. Read through Section D, 'Representations'. Carefully affirm the accuracy of your statements and sign where indicated, ensuring your signature is not a stamp.
8. Review the completed application for any missing information. Save changes and ensure to download, print, or share the form as per your requirements.

Begin your application process online today to ensure a smooth contracting experience.