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Get Mn Bluecross Provider Demographic Change Form 2019-2025
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How to fill out the MN BlueCross Provider Demographic Change Form online
Filling out the MN BlueCross Provider Demographic Change Form is essential for updating your provider information accurately. This guide will walk you through each section of the form, making the process straightforward and efficient.
Follow the steps to complete the form correctly.
- Click the ‘Get Form’ button to access the document. This will allow you to open the form in a suitable editor for completion.
- Identify the purpose of your request by checking all applicable changes, such as address, phone number, or name adjustments. Make sure to provide the effective date of change.
- Confirm your current information. Fill in fields that match your W-9 form, including the legal business name, doing business as (DBA) name, physical address, and NPI or UMPI numbers.
- Make changes to your information by selecting the relevant checkboxes for the modifications you are requesting. Include all necessary details related to the address, phone, and website.
- If you are affiliated with multiple hospitals, list each hospital's name and address in the designated area, ensuring to indicate whether you are accepting new patients.
- Provide your regular clinic office hours and your urgent care office hours, using the specified format for clarity on the times you are open for service.
- Complete the accessibility section by indicating whether your office and exam rooms are handicap accessible, along with any relevant equipment.
- Address cultural competency by confirming if your staff has completed training within the past year and providing the date if applicable.
- In the additional information box, enter any further details or notes that are necessary for processing your request.
- Finally, provide your name and title, email address, and phone number. Confirm your authority to submit the changes on behalf of the provider, then submit the completed form via email.
Complete your documents online to ensure timely processing of your requests.
If you need to send documentation to Prime Therapeutics regarding Medicare, you should use their dedicated fax number. This number is listed on their website and within provider resources. When sending the MN BlueCross Provider Demographic Change Form, ensure your documents are complete to avoid processing issues.
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