Get Provider Demographic Change Form - Bluecross Blueshield Of ...

Filling out the Provider Demographic Change Form is an essential process for healthcare providers to update their demographic information accurately. This guide provides step-by-step instructions to assist users in completing the form online with ease and clarity.

Follow the steps to complete your Provider Demographic Change Form.

1. Press the ‘Get Form’ button to access the Provider Demographic Change Form. This will allow you to open it in your preferred editing platform.
2. Begin by filling out Section I: Demographic Data. Include your full name, title, NPI number, CAQH number, and optional ethnic information. Ensure all fields are completed as accurately as possible.
3. Proceed to Section II: Data Change Summary. Indicate the purpose of the update by checking the appropriate boxes. Specify if you are adding a location, changing an address, or making other changes. Fill in effective dates and any relevant identifiers.
4. In Section III: Data Change Detail, provide the new and old information for any changes you are making. Ensure that only the information relevant to your updates is included, using separate sheets if necessary for multiple changes.
5. Complete Section IV regarding wheelchair accessibility if applicable. Indicate how wheelchair-dependent patients are accommodated if your office is not wheelchair accessible.
6. Fill out Section V related to on-call physician coverage if applicable. List details for each physician covering for you, ensuring that their specialties align with yours.
7. Finally, review the entire form for accuracy, input your printed name, contact method, sign the form, and date it. Once completed, save your changes, choose to download, print, or share the form as needed.

Take the next step in updating your information by completing your Provider Demographic Change Form online today.