Get Tx Blue Cross And Blue Shield Ancillary Provider Id Request Form 2019-2025

Filling out the TX Blue Cross And Blue Shield Ancillary Provider ID Request Form online is a crucial step for providers seeking to establish an out-of-network provider ID. This guide outlines the necessary steps to ensure that your application is completed accurately and efficiently.

Follow the steps to successfully complete the Ancillary Provider ID request form.

1. Click the 'Get Form' button to obtain the form and open it in your document editor.
2. Begin by entering the date at the top of the form. This date is essential for processing your application.
3. In the 'Attn' section, specify 'Facility Provider Services' to ensure that your form reaches the correct department.
4. Fill out the provider of service information, including the corporate name, address of the physical location, 'DBA' name, city, county, and type of facility, product, or services offered.
5. Provide your contact information, including phone number, fax number, email address, NPI, state, and zip code.
6. Enter your Federal Tax ID number and specify the payee address where checks should be mailed.
7. If applicable, complete the section for adding an affiliate location to a parent hospital, selecting whether the provider has been deemed ‘Provider Based Status’ and answering the associated questions.
8. Ensure you review all information for accuracy. Sign and date the form where indicated to certify that the information provided is correct and complete.
9. Attach the required documents, including the facility license, a signed and dated W-9 form, and NPI confirmation.
10. Once you have completed the form and attached the necessary documents, save your changes, download, print, or share the form as needed.

Complete your TX Blue Cross And Blue Shield Ancillary Provider ID Request Form online today!