Get Highmark Participating Provider Agreement Form

Filling out the Highmark Participating Provider Agreement Form online is essential for becoming a registered provider with Highmark Blue Shield. This guide provides clear, step-by-step instructions to help you navigate the process smoothly.

Follow the steps to complete the agreement efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name as it appears on your license in the designated field for 'Name - Please print'.
3. Provide your main practice address, including the street address, city, state, and ZIP code. Ensure all details are accurate to prevent any issues with correspondence.
4. Enter your telephone number and specialty in the respective fields. This information is crucial for identification and communication purposes.
5. You will be required to input your Social Security number and Pennsylvania license number. Make sure these numbers are accurate and up-to-date.
6. If your mailing address differs from your main practice address, complete the mailing address section. This is where all administrative correspondences will be directed.
7. If you have had a previous main practice address within the last two years, include this information as well.
8. You must attach a current copy of your Pennsylvania license to the form before submission.
9. After completing all fields, review the form for accuracy. Make necessary corrections if you find any errors.
10. Finally, save your changes, and choose to download, print, or share the form online for submission to the relevant department.

Complete your Highmark Participating Provider Agreement Form online now to ensure a smooth registration process.