Get Non-network Provider Written Direction Of Payment

Filling out the Non-Network Provider Written Direction Of Payment form is a straightforward process that allows you to direct Blue Cross & Blue Shield of Mississippi to make benefit payments to your selected provider. This guide will help you understand the components of the form and provide step-by-step instructions to complete it online.

Follow the steps to complete your payment direction form.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate online tool.
2. Locate the field labeled 'Insured’s Name' and enter your full name as it appears on your insurance policy.
3. In the 'Insured’s Blue Cross & Blue Shield of Mississippi Identification Number' field, provide your identification number associated with your insurance plan.
4. Find the section for 'Non-Network Provider' and input the name of the provider you wish to receive payment.
5. In the 'Date(s) of Service' area, enter the specific date or dates when the services were rendered to you.
6. Review the statement where you acknowledge that you understand the payment direction. This confirms that the provider will accept payment in full for covered services, and you are aware of any deductible or co-payment responsibilities.
7. Sign and date the form in the designated fields. Make sure the signature is clear and matches the name you provided.
8. Once all information is accurately completed, ensure to save the changes, download a copy for your records, or print the form for submission.
9. Submit the completed form to the Non-Network Provider by faxing it to 601-664-5003 as per the provided instructions.

Complete your Non-Network Provider Written Direction Of Payment form online today!