Get Blue Cross And Blue Shield Of Minnesota Provider Demographic Change Form Fax To: (651) 662-6684 Or

This guide provides step-by-step instructions for completing the Blue Cross And Blue Shield Of Minnesota Provider Demographic Change Form. Whether you are updating your contact details, hospital affiliations, or office hours, these clear instructions will help you submit your changes accurately.

Follow the steps to accurately fill out the demographic change form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by entering the effective date of the change at the top of the form. This ensures that your updated information is recognized from the specified date.
3. In the 'Tax ID #' section, provide your current tax identification number as it appears on file.
4. Complete the 'Old Information' section, which includes fields for the legal name, NPI/UMPI number, and doing business as (DBA) name.
5. Fill in the physical, mailing, and billing addresses. Ensure that all address fields are filled out correctly, including city and zip code.
6. Switch to the 'New Information' section and provide the updated legal name, NPI/UMPI number, and DBA name if applicable.
7. For the physical, mailing, and billing addresses, indicate if there are any changes; if there are no changes, simply mark them as 'Unchanged.'
8. Address the additional questions regarding wheelchair access, mail delivery at the location, and whether you are accepting new patients.
9. In the 'Hospital Affiliations' section, provide the necessary details including addresses and operational hours.
10. Finish by indicating who is completing the form. Provide a digital signature, phone number, email address, and fax number for communication.
11. Once all fields are completed, you may save changes, download, print the form, or share it as required.

Take the next step in updating your information by completing the form online today.