Get Highmark Provider Form 9101

The Highmark Provider Form 9101 is essential for various provider-related requests, including adding or deleting practitioners, changing addresses, and adjusting account details. This guide provides step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete the Highmark Provider Form 9101.

1. Click 'Get Form' button to obtain the form and access it for online completion.
2. Begin with Section 1, required for all requests. Fill in the name of the account (DBA name), Tax ID, Type 2 National Provider Identifier (NPI), and Highmark Group Number.
3. If you are adding or deleting a practitioner, proceed to Section 2. Provide the effective date of the addition/change, practitioner’s date of birth, name, CAQH ID, Type I NPI, and specialty. Indicate whether you are adding or deleting the practitioner.
4. For any address changes, complete Section 3. Specify the effective date of the change, and indicate whether you are adding or changing the main practice address, additional practice addresses, check address, and mailing address. Provide telephone and fax numbers as necessary and ensure that the main practice address does not use a PO Box.
5. If requesting an Assignment Account or Pay-To Account, complete Section 4. Identify whether the requesting entity is an urgent care facility or retail clinic, and detail the legal entity type and relationship between the legal entity and provider.
6. For changes to the group name, DBA name, or Tax ID, navigate to Section 5. Fill in the new name details and effective dates for the group account, DBA name, and Tax ID where applicable.
7. Finally, in Section 6, ensure the Authorized Representative signs the form. This section requires agreement to several statements regarding billing and changes in the practice. Include the representative's date, title, and telephone number.
8. Once completed, remember to save any changes made to the form. You can download, print, or share the final version as needed.

Complete your Highmark Provider Form 9101 online today to ensure a smooth processing experience.