Get Non Pmd Provider Application - Blue Cross And Blue Shield Of ... - Bcbsal

This guide provides comprehensive instructions on how to accurately complete the Non PMD Provider Application for Blue Cross and Blue Shield of Alabama online. Following these steps will assist you in submitting your application successfully and efficiently.

Follow the steps to accurately complete the application form online.

1. Click the ‘Get Form’ button to obtain the application and open it in the designated editor.
2. Begin filling out the practitioner information section. Input your first name, middle name, last name, and suffix. Don't forget to include your Social Security Number, and state whether you are a U.S. citizen.
3. Provide your email address and indicate your date of birth, state of birth, and county of birth. Enter your professional title and preferred name.
4. Fill in your National Provider Identifier (NPI) and Tax ID Number, and if applicable, include your Alien Registration Number.
5. Indicate if you are fluent in any other languages besides English, and list them if applicable.
6. Complete the Primary Practice Information section, including your legal practice name, tax ID, and office address details.
7. Indicate your office telephone number, email address, and whether you are currently accepting new patients.
8. Provide information regarding your practice specialties and any additional locations if necessary.
9. In the Provider Information section, list your office contact details, practice type, and whether handicap access is available.
10. Complete the section on professional education, including all degrees and training received, along with corresponding dates.
11. Answer all the questions in the sections on licensing, insurance, and any relevant history concerning certifications.
12. For the questions and answers section, respond to all inquiries as accurately as possible, providing explanations for any affirmative answers.
13. Finally, review your application thoroughly to ensure all information is accurate, sign the attestation statement, and prepare to submit.
14. Once completed, save changes, download the form, or print a copy for your records before submitting it.

Fill out your application online today to ensure timely processing.