Get Group Provider Record Id Information Form - Blue Cross And Blue ...

Completing the Group Provider Record ID Information Form is essential for providers who practice within a group or corporate setting. This guide provides clear, step-by-step instructions to help you fill out the form online accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Provide your practice information in Section A. Include the name of your group or company as it appears on the W-9 form, address, specialty, and contact information. Ensure to list only one specialty, which represents the majority practice area.
3. For Section B, enter your Tax Identification Number (TIN) or Employer Identification Number (EIN). Confirm whether it is your personal taxpayer number or if it belongs to a corporation or partnership.
4. Fill in the contact name for billing and provide the accounting address where checks should be mailed, if different from the practice address. Include relevant phone and fax numbers.
5. Complete the Group Member Information Form for each practitioner in your group. This requires providing each individual’s Type 1 NPI, specialty, practice location, and contact information.
6. Attach a copy of the entity's W-9 form and the state license for each provider affiliated with your organization. Be reminded that incomplete submissions will be returned.
7. Review all the information you have entered to ensure accuracy and completeness. Once confirmed, save your changes and proceed to download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing.