Loading
Get Ca Blue Shield Icf-01 2020-2026
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CA Blue Shield ICF-01 online
The CA Blue Shield Individual Practitioner Information Change Form (ICF-01) allows users to update essential details of an existing practitioner record. This guide provides clear, step-by-step instructions for completing the form efficiently and accurately online.
Follow the steps to complete the CA Blue Shield ICF-01 form online
- Click the 'Get Form' button to obtain the CA Blue Shield ICF-01 and open it in the online editor.
- Identify the practitioner requiring changes by populating the Practitioner Name, Tax Identification Number (TIN), and National Provider Identifier (NPI) fields. Ensure all applicable fields with required changes are completed.
- For changes to your corporation or business structure, please attach the Articles of Incorporation. If your request concerns a change to your Employer Identification Number (EIN) or TIN, include a signed W-9 or relevant IRS document.
- Indicate the type of change you are making (Add, Change, Remove) by checking the appropriate box. For added information, complete the 'New' column; for changes, fill in both the 'Existing' and 'New' columns; for removals, use the 'Existing' column only.
- Fill out the remaining sections of the form, including practitioner specialties, languages, hospital affiliations, and any other relevant details.
- After reviewing the form for accuracy, save your changes. You can download, print, or share the form as needed.
- Return the completed form and all required documentation to Blue Shield and/or Blue Shield Promise via email at BSCProviderInfo@blueshieldca.com.
Complete your forms online today for a streamlined process.
Claims received during the tenth through twelfth month after the month of service will be reimbursed at 50 percent of the payable amount. Claims received after the twelfth month following the month of service will be denied.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.