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Get Highmark Participating Provider Agreement Form

Account Group Account number IRS number Effective date of change Practice address Specialty Change current specialty Note: For address changes, please complete the PDS Change of Address form (9111). Provider name (Typed or printed) Provider number Social Security number Provider signature (Required for additions) Applicable to: All Highmark Blue Shield networks Indicate Add 1 Delete 2 1 By my signature, I, as a member of this account, fully agree to abide by the requirements listed o.

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