Get Out-of-state / Eft New Provider Enrollment Form (pdf) - Bcbsm.com

Filling out the Out-of-State / EFT New Provider Enrollment Form accurately is essential for a smooth enrollment process. This guide provides clear, step-by-step instructions to help users navigate through the form with ease.

Follow the steps to complete your enrollment form online.

1. Press the ‘Get Form’ button to access the enrollment form and open it using your preferred PDF editor.
2. Begin with Section 1, Demographic Data. Enter your name, Medicare number, and select your provider type. Make sure to check all applicable options.
3. In Section 2, EIN/SSN Tax information, provide your EIN Tax ID number and SSN (if you are a practitioner). Ensure the information matches your IRS documents.
4. Proceed to Section 3, Address Information. Fill in your primary office address, including street address, city, state, and ZIP code. Also, provide the primary telephone number that patients can use.
5. In Section 4, Provider secured services, complete the relevant fields, including your name, title, and the email address for electronic communications.
6. Finally, in Section 5, Application Signature, certify that the information provided is true and complete. Obtain the necessary signature and date before submission.
7. Once you have filled out the form completely, you can save your changes, download the form, print it, or share it as required for submission.

Complete your Out-of-State / EFT New Provider Enrollment Form online today to streamline your enrollment process.