Loading
Get Premera Bcbs Form 014664 2005-2025
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 Premera BCBS Form 014664 online
This guide provides clear and supportive instructions on how to fill out the Premera BCBS Form 014664 online. Follow these steps to ensure accurate completion for efficient processing.
Follow the steps to successfully complete the form online.
- Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
- Begin by entering the practitioner's name in the designated fields: first name, middle initial, and last name.
- Provide the practitioner's Social Security number and date of birth, ensuring to select their gender.
- Fill in the state license number and specify the state of licensure. If applicable, include any additional state licenses.
- Include the DSHS number, UPIN number, DEA number, and Medicare number if relevant.
- Enter the individual NPI number and any foreign languages spoken by the practitioner.
- List the primary specialty and check the appropriate board status. Also, ensure to include any secondary specialty and corresponding board status.
- Fill in the clinic or group name along with the group NPI number and the start date at the clinic or group.
- Complete the primary practice address with street, city, state, and zip code.
- Indicate the services available, such as wheelchair accessibility and interpretive services.
- Provide the tax ID number, office hours, and contact phone numbers.
- Complete the pay-to address and mailing address for correspondence.
- Enter the email addresses for both the clinic and the practitioner.
- If there are multiple practice locations, attach a list with the required information for each location.
- Finally, document who completed the form and the date of completion.
- After filling out all sections, you may save your changes, download, print, or share the completed form.
Complete your Premera BCBS Form 014664 online for a smooth submission process.
No, Premera Blue Cross is not leaving Washington state. They remain committed to providing quality health insurance options to residents. If you're interested in navigating your options or need the Premera BCBS Form 014664, our platform can guide you in finding the appropriate forms and resources.
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.