Application For Clinic/group/institution/location To File Claims Or To Change Employer Identification Number (Ein) Form

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Application For Clinic/Group/Institution/Location to
File Claims or to Change Employer Identification Number (EIN)
Please complete this form to notify BlueCross BlueShield of South Carolina and BlueChoice HealthPlan of the creation of a new location
that wishes to file claims for Preferred Blue
(PPC), BlueChoice HealthPlan, BlueChoice HealthPlan Medicaid, the State Health Plan and/
®
or FEP. You must verify your EIN by submitting one of these: Letter 147C, CP 575 E or tax coupon 8109-C.
Please include a copy of the National Plan and Provider Enumeration System (NPPES) NPI notification with this application.
Note: Do not file claims to BlueCross with your NPI at this time. Continue to file claims with your BlueCross provider numbers only.
Fax the completed form and appropriate documentation to 803-264-4795. If you have questions about this form, email
.
Clear Form
This form does not qualify you to be a network provider.
(Please type or print)
Date of Request: __________________________
Name of Business:
Federal Tax ID (EIN):
Effective Date:
Date Clinic/Group Open for Business:
Previous Tax ID, if applicable:
If the new EIN is a result of a merger or acquisition, were the assets and liabilities purchased? (Yes, No or N/A)
*National Provider Identifier (NPI):
Old NPI, if applicable:
Practice/Institution Location Address:
Payment Address:
County:
County:
Practice Appointment Phone #:
Practice Fax #:
*Required
Type of Business:
Professional Assoc/Clinic/Partnership
Skilled Nursing Facility
Independent Clinical Lab
M
M
M
General Acute Care Hospital
Home Health Agency
Physiological Lab
M
M
M
Rehabilitation Institution
Hospice
Portable X-Ray Supplier
M
M
M
Psychiatric Institution
Pharmacy Only
Outpatient Diagnostic Ctr.
M
M
M
Alcohol/Substance Abuse Institution
Pharmacy with DME Sales
Orthotics/Prosthetics
M
M
M
Durable Medical Equipment (DME)
Other (Specify)__________________________________________________
M
M
All professional associations, corporations, partnerships and clinics must complete this section:
Medicare Group #:
List each practitioner who will be providing services at this location:
Name
Social Security #
NPI
Primary Specialty
(10/11)

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