Get Excellus Bcbs Application For Non-physician Health Care Practitioner 2022-2025

This guide provides step-by-step instructions on how to complete the Excellus BCBS Application For Non-Physician Health Care Practitioner online. By following these instructions, users can ensure that they properly fill out the application and submit the necessary documentation.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your requested effective date and the type of request you are submitting, such as a first-time application or a demographic change. Ensure you review any options regarding temporary participation if applicable.
3. Specify your role by selecting the appropriate option, such as Nurse Practitioner or Licensed Master Social Worker. Ensure that you provide your last name, first name, middle initial, and date of birth.
4. Enter your Social Security number, individual NPI number, and provide your non-physician taxonomy code and license number along with the license state.
5. Input your DEA certificate number and state, as well as Medicare and Medicaid numbers if applicable. Note that an active Medicaid ID is necessary for Medicaid products, except for LMSW or LCAT.
6. Indicate any additional languages spoken beyond English and provide the name and NPI number of your collaborating physician. Ensure that the collaborating physician meets the required qualifications.
7. Proceed to fill out your primary office address, ensuring that all information is complete with street level addresses and valid US mailing details. Include fax and phone numbers and indicate accessibility.
8. Continue to provide additional addresses for correspondence, medical records, and remittance as required. Ensure that these addresses conform to the guidelines regarding accessibility.
9. Sign the applicant attestation and include the date. Ensure all information is accurate to the best of your knowledge.
10. Have the collaborating physician sign their attestation, filling in their name, date, and confirming their contact details.
11. Once you have completed the form, review it for accuracy. You can save your changes, download a copy for your records, and share it if needed.

Begin completing the Excellus BCBS Application For Non-Physician Health Care Practitioner online today to ensure your enrollment process goes smoothly.