Get Blue Shield Of California Provider Identification Number Application Form
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How to fill out the Blue Shield Of California Provider Identification Number Application Form online
Filling out the Blue Shield Of California Provider Identification Number Application Form online is a straightforward process that ensures you provide all necessary information. This guide will walk you through each section of the form, making it easier to submit your application accurately and efficiently.
Follow the steps to complete your application form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with section A, providing your service information. Fill in your name (for individual applicants), gender, title or degree, and license number. If applying for a group, enter the name of the business or corporation along with the primary specialty or type of service.
- Provide the physical location address where you offer services. Make sure to include your street address, suite number (if applicable), city, state, and ZIP code. Indicate if wheelchair access is available and the languages spoken.
- In section B, enter the billing reimbursement information. Specify the billing address where checks should be mailed, including all relevant address details and the billing location phone number.
- Complete the tax identification details. Ensure to include your Social Security number, tax ID/employer ID number (if applicable), and select the type of business that best describes your operation.
- List any prior practice addresses or groups that you are no longer affiliated with. If you have more than one, attach a separate sheet of paper.
- If you're signing on behalf of a provider, provide the name and title of the person authorized to sign. If this is for a group or corporation, include the names and license numbers of all licensed professionals providing services.
- In section C, certify that all information is accurate and complete by providing your signature, title, and date. Please make note of the important information that states the provider identification number is for billing purposes only.
- Review your completed form for accuracy. You can then save changes, download, print, or share the form as needed.
Complete your application online to start the process of obtaining your Provider Identification Number today.
The billing provider's tax ID number (TIN) and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.
Fill Blue Shield Of California Provider Identification Number Application Form
One application per service location is required. Get all of your applications, request forms, and credentialing information in one place for all lines of business (Commercial, Medicare and Medi-Cal). Identify the practitioner requiring a billing record and complete all fields with the practitioner information. Application Type: (select one). CAQH – CAQH Number Required: CPPA, NPMP, or AHPA – PDF of application required. Credentialing Application. Completed, signed and dated attached California Participating Practitioner. Application. What you'll need to get started: • A designated Account Manager to register the account. • Your Tax ID (TIN) or Social Security number (SSN).
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