Application For Clinic/group/institution/location To File Claims Or To Change Employer Identification Number (Ein) Form Page 2
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1
2All hospitals, institutions and other facilities must complete this section:
License #:_____________________________ (attach copy of license)
Are you JCAHO accredited?
No
Yes (attach copy of accreditation)
M
M
Are you state certified?
No
Yes (attach copy of certification)
M
M
Are you cardiac rehabilitation certified?
No
Yes (attach copy of certification)
M
M
Member Certification #:_____________________ Certification Date:________________ (attach copy of Medicare certification)
Indicate the number of beds, excluding exempt units: ________________
All ambulance services must complete this section:
The ambulance company bills all patients for rendered services.
Yes
No
M
M
The ambulance company is a voluntary ambulance company.
Yes
No
M
M
The ambulance company is a government subsidized company.
Yes
No
M
M
Please check the appropriate boxes. I certify that the above named ambulance company meets the following requirements:
Each of the company’s ambulance vehicles are specially designed and equipped for emergency transportation of the sick or injured.
M
The minimum ambulance crew consists of at least two members, one of whom has a minimum training at least equivalent to that
M
provided by the advanced Red Cross First Aid course.
The ambulance company agrees to notify BlueCross BlueShield of South Carolina and BlueChoice HealthPlan of any change in
M
company ownership and/or operation which results in these:
• T he use of vehicles as ambulances which are not specially designed and equipped for emergency transportation of the sick or
injured.
• T he minimum first aid requirement for crew members is less than the advanced Red Cross First Aid course equivalent.
• T he political jurisdiction in which the ambulance company is based requires a license to operate an ambulance service within its
jurisdiction.
All applicants must complete this section:
Date Legal Entity Established: ________________________________
List Each Owner:
Name
Title
Social Security #
Contact Person:__________________________________________ Contact Person’s Phone #:_____________________________
Email Address (required for notification when we complete changes):__________________________________________________
Enter text directly into the form by placing your cursor on each blank. Click on boxes to select them, or tab to them and
press your spacebar. You can also save this form to your computer. Use the “Clear Form” button on the first page to delete
all answers. Print the form and fax it to us to complete your application.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan are independent licensees of the Blue Cross and Blue Shield Association.
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