WF 10577 AUG 12 Page 1 of 10

Provider EnrollmentBlue Cross Blue Shield of MichiganP.O. Box 217,Southfield Mi, 48034

Questions? Call 1-800-822-2761

3. You can also mail the completed forms and documentation to:

2. Fax the registration form and attachments (i.e., signature documents) to 1-866-900-0250. Forms for multiple practitioners and groups cannot be bundled into one fax transmission.

1. BCBSM’s fax cover sheet must be the first page of your form submission. Not your personal fax cover sheet.

Instructions for form submission

Tax identification number. Type 2 NPI National Provider Identifier. Date (MM/DD/YY). From (Insert name of contact person).For group practices. Tax identification number. Type 2 NPI National Provider Identifier. Date (MM/DD/YY). From (Insert name of contact person).For allied providers.

Instructions for fax cover sheet

We cannot accept handwritten forms. To ensure forms are processed timely,please adhere to the following instructions:

1. Do not hand write anywhere on the fax cover sheet, otherwise processing will be delayed.

2. Enter all information online; press the tab key after each entry to move from field to field.

For individual practitioners.Type 1 NPI National Provider Identifier. Date (MM/DD/YY). From (Insert name of contact person).10 digit state license number.When adding an individual to an existing group be sure toinclude your group’s Type 2 National Provider Identifier and a group change form

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WF 10577 AUG 12

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

10577Form Number:

Mail to: Provider EnrollmentBlue Cross Blue Shield of Michigan

Southfield, MI 48034P.O. Box 217

Date:

From:

Fax To: 866-900-0250 Provider Enrollment

IMPORTANT: Attach this page to the top of your document toavoid processing delays.

FAX OR MAIL COVER SHEETFOR DOCUMENTS

Page 2 of 10

Type 1 NPI:

State License Number:

Type 2 NPI:

NEW ALLIED PRACTITIONER ENROLLMENT FORM

Type 1 National provider identifier

Please complete this form if you are an anesthesia assistant, audiologist, certified nurse mid-wife, certified nurse practitioner, certified registered nurse anesthetist, hearing aid dealer, optometrist orthotic supplier, physician assistant, prosthetic supplier, or prosthetic and orthotic supplier (with an individual certification) applying to Blue Cross Blue Shield of Michigan and Blue Care Network for the first time. Note: If you are an orthotic supplier, prosthetic supplier or prosthetic and orthotic supplier with a facility certification, please complete the New Allied Provider Enrollment form.

State license number

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You (except anesthesia assistants) are required to complete and maintain a credentialing application through the Council for Affordable Quality Healthcare® at http://upd.caqh.org/oas/ In order for your managed care affiliation request to be processed you must complete your CAQH application within 14 calendar days. If you have already completed a CAQH application, your attestation must be up to date. If your CAQH application is not complete or if your attestation is expired after 14 calendar days, your request will be closed and you will need to reapply using the Allied Provider Change form.

Type 2 National provider identifier

*First name Middle name

*Last nameSuffix II III IV Jr. Sr.

*What type of providerare you?

anesthesia assistant

audiologistcertified nurse midwife

hearing aid dealercertified registered nurse anesthetistcertified nurse practitioner

*County where your primary addrerss is located

*Degree *Date of birth

Gender Male Female Preferred saluation Dr. Ms. Mrs. Mr. Miss

Section 1: Demographic Data

optometrist

orthotic supplier

prosthetic supplier

physician assistantprosthetic & orthotic supplier

NEW ALLIED PRACTITIONER ENROLLMENT FORM

*denotes a required field

Section 1: Demographic Data - continued

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Race/Ethnicity

Black or African AmericanWhite/Caucasian

American Indian or Alaska Native

Chinese/Chinese-AmericanAsian

FilipinoJapanese/Japanese-AmericanKorean

Native Hawaiian or other Pacific Islander

Vietnamese

Mexican/Mexican-AmericanHispanic/Latin AmericanArabOther RaceAssyrian/ChaldeanOther AsianMultiracial

Section 2: Employer ID number/Tax information

*Social Security number

*Is your EIN/Tax ID number the same as your SSN?

Tax exempt

EIN/Tax name as indicated on IRS document

Yes No

If you would like to bill with your Type 2 NPI (National provider identifier) representing your incorporated individual business, you must also complete a New Group Enrollment form to register this entity as a group.

Type 1 National provider identifier State license number

Not Disclosed

Type 2 National provider identifier

If registered with CAQH, CAQH ID number:

*denotes a required field

Yes No (If no. enter Tax ID number)

EIN/Tax ID number

NEW ALLIED PRACTITIONER ENROLLMENT FORM

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BCBSM and BCN do not permit retroactive effective dates.

Section 3: Request networks You will be notified of your status and the effective dates of affiliation in BCBSM and BCN managed care networks after credentialing for the networks is completed and BCBSM and BCN has counter-signed your affiliation agreements. Important: If applying to participate with Traditional, Vision, Hearing, TRUST PPO, Medicare Advantage PPO, BCN Commercial, BCN Advantage HMO , Blue Preferred Plus, please return an Individual Signature Document for each network.

Select networks you are applying to:

Provider Type Eligible Networks for Provider Type

anesthesia assistant

optometrist

certified nurse midwife

hearing aid dealer

Traditional

Hearing

Medicare Advantage PPO

BCN Commercial

BCN Advantage HMOSM

Traditional

BCN Commercial

BCN Commerical

BCN Advantage HMOSM

audiologist

Medicare Advantage PPO

Traditional Vision

BCN CommericalMedicare Advantage PPO

BCN Advantage HMOSM

certified nurse anesthetistTraditional Medicare Advantage PPO

certified nurse practitioner Traditional Medicare Advantage PPO

BCN Advantage HMOSM

BCN Commercial as a primary care practitioner

Name of Medical Care Group endorsing you as a PCP:

Number of Medical Care Group endorsing you as a PCP:

BCN Commercial BCN Advantage HMOSM

Traditional Medicare Advantage PPO orthotic supplierprosthetic supplierprosthetic & orthotic supplier

BCBSM and BCN do not permit retroactive effective dates in managed care networks.

Type 1 National provider identifier State license number

Blue Cross Complete

Blue Cross Complete

Blue Cross Complete

Blue Cross Complete

Blue Cross Complete

Type 2 National provider identifier

SM

NEW ALLIED PRACTITIONER ENROLLMENT FORM

physician assistant Eligibility based upon supervising physician’s eligibility

Hearing

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Type 1 National provider identifier State license number Type 2 National provider identifier

Section 4: Address Data *denotes a required field

Primary address (must be an address where health care services are rendered and may be published in BCBSM/BCN provider directories)

*Primary Telephone Number Fax Number

*Street Address

*City *State *Zip Code

Primary Telephone Number must be a phone number patients can call to make an appointment.

Payment/Remit address (if different from your primary address)Street Address

City State Zip Code

Mailing address (if different from your primary address)Street Address

City State Zip Code

Payment/Remit telephone number (if different from your Primary telephone number)

Mailing contact name Mailing contact phone number

Primary address - Accessiblity

*Handicap accessibility: Yes No *Accessible by train: Yes No *Accessible by bus: Yes No

Credentialing Contact informationPlease provide the name and contact information of a person who can answer questions about information in this application

* First Name Last Name

* Telephone Number Fax Number

Email Preferred method of contact? Email US Mail

extension

NEW ALLIED PRACTITIONER ENROLLMENT FORM

Is your primary office address a personal residence? Yes No

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Type 1 National provider identifier State license number

Section 5: Additional practice locations

Street Address

City State Zip Code

#1

*Handicap accessibility: Yes No *Accessible by train: Yes No *Accessible by bus: Yes No

Telephone Number Fax Number

Close Time

Open Time

Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you provide 24/7 coverage at this location? Yes No

Type 2 National provider identifier

Section 4: Address Data - continued

Primary Address – Office Hours

Close Time

Open Time

Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday

*Do you have 24/7 coverage at this location? Yes No

*denotes a required field

All provider services:

Do you have e-prescribing functionality? Yes No

Do you provide in-home physician visits? Yes No

(Must be an address where health care services are rendered and may be published in BCBSM/BCN provider directories)

NEW ALLIED PRACTITIONER ENROLLMENT FORM

Is your primary office address a personal residence? Yes No

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Type 2 National provider identifier State license number Type 2 National provider identifier

Section 5: Additional practice locations - continued

Street Address

City State Zip Code

#2

*Handicap accessibility: Yes No *Accessible by train: Yes No *Accessible by bus: Yes No

Telephone Number Fax Number

Close Time

Open Time

Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you provide 24/7 coverage at this location? Yes No

Street Address

City State Zip Code

#3

*Handicap accessibility: Yes No *Accessible by train: Yes No *Accessible by bus: Yes No

Telephone Number Fax Number

Close Time

Open Time

Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you provide 24/7 coverage at this location? Yes No

If you have additional locations, please list and attach separately.

*denotes a required field

NEW ALLIED PRACTITIONER ENROLLMENT FORM

Is your primary office address a personal residence? Yes No

Is your primary office address a personal residence? Yes No

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Type 2 National provider identifier Type 1 National provider identifier State license number

Section 6: Provider Secured Services *denotes a required field Doing business electronically saves your office time and money. We encourage you to sign up for Provider Secured Services, a free service for BCBSM and BCN participating providers that allows you to view patient eligibility, track claims, and much more online. Begin the process by completing the information in the section below:

Authorized Web Access AdministratorProvide the name and contact information of the person who is the authorized Web Access Administrator with delegated authority to manage all access to protected health information and group practitioner records using provider secured (web) self services.* Name (type or print) *Title

* Telephone Number *E-mail

* Does the practice currently use Provider Secured Services? Yes No

Provider Secured Services AccessComplete the section below for individuals that do not have an existing Provider Secured Services(web-DENIS) login ID. Only check off the minimum necessary features for each user listed below.

* Name (full legal name of each user) *Telephone Number

EligibilityCoverageSearches Only

Claims Tracking & EFT

Provider Claims Correction (PCC)

For BCBSM Use Only

* Name 1. * Telephone Number

* Name 2. * Telephone Number

* Name 3. * Telephone Number

* Name 4. * Telephone Number

NEW ALLIED PRACTITIONER ENROLLMENT FORM

Existing Provider Secured Service users that would like to update their access to include the NPI (s)indicated on this form complete:

Section 6A: Professional/Facility Providers - Authorization to update user access for Provider Secured Services

Section 6B: Billing Services - Authorization to update user access for Provider Secured Services

BCN PCP ClaimsSummary

e-referral(BCN Only)

If no and you are requesting user access below, complete the Use and Protection Agreement and return with this application.

*Print or Type Name *Practitioner Signature/Title *Date

Section 7: Application signature *denotes a required field

Provider Secured Services

Type 2 National provider identifier Type 1 National provider identifier State license number

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NEW ALLIED PRACTITIONER ENROLLMENT FORM

The authorized signer agrees that he/she has the company’s designated authority to request and maintain minimum necessary Web access and is responsible for complying with all terms and conditionscontained within the Provider Secured Services Use and Protection Agreement.

Section 6A: Professional/Facility Provider - Authorization to update user access for ProviderSecured Services

Enter the user ID(s) below to be updated with the NPI(s) indicated on this form.

Section 6B: Billing Services - Authorization to update user access for Provider Secured Services

Complete Addendum “B” Authorization for Representative Access (PDF) to add NPI(s) to your existing Provider Secured Service ID.

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I certify that:The information contained in this application is true and complete. I will notify Blue Cross Blue Shield of Michigan and Blue Care Network immediately in writing of changes affecting this data. If I am a practitioner in training, I will not report services that are related to my training program and rendered at the address from which I am training. Should I re-enter training, I will notify BCBSM and BCN.

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