Get Ancillary Provider Id Request Form Blue Cross And

Filling out the Ancillary Provider ID Request Form for Blue Cross and Blue Shield of Texas is a straightforward process that ensures your information is accurately captured for claims processing. This guide will walk you through each section of the form to assist you in completing it online.

Follow the steps to accurately complete the Ancillary Provider ID Request Form.

1. Press the ‘Get Form’ button to access the Ancillary Provider ID Request Form and open it in your preferred online editor.
2. Begin by entering the date at the top of the form. This is important for documentation and processing.
3. In the 'Attn' line, specify 'Facility Provider Services' to direct your submission to the correct department.
4. Fill in the provided fax number for timely communication, which is 972-766-7315.
5. Complete the 'Provider of Service Information' section with the corporate name as stated on line 1 of your W-9 form.
6. Enter the physical address of your place of practice, including suite number if applicable, along with the city, county, state, and zip code.
7. Provide the 'DBA Name' as listed on line 2 of your W-9 form, ensuring it matches your business entity.
8. Indicate the type of facility, products, or services you offer, and include your contact phone number, fax number, and email address.
9. Input your Medicare number and NPI (National Provider Identifier) as required for identification.
10. Next, complete the 'Tax I.D Information' section by providing your Federal Tax Identification Number.
11. In the 'Payee Address/Mail Check To' section, repeat the necessary address information ensuring it aligns with your mailing preferences.
12. If applicable, complete the section regarding the Affiliate location by checking the relevant option and providing necessary details about the provider's status.
13. At the end of the form, review your information for accuracy. After verifying, add your signature along with that of an authorized representative, and include your title and date of signing.
14. Make sure to attach copies of the required documents, including your facility license, W-9 form, and NPI confirmation.
15. Once all sections are complete and documents attached, save your changes, and download, print, or share the form as needed.

Complete your Ancillary Provider ID Request Form online today for efficient processing.