Provider Change Form - Blue Cross Blue Shield Arizona Advantage
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1
2Blue Cross® Blue Shield® of Arizona Advantage
Provider Change Form
NOTE regarding address changes: If BCBSAZ Advantage does not receive a new address from the provider in writing, BCBSAZ Advantage will continue sending
correspondence, including claims payments, to the address currently listed in BCBSAZ Advantage’s system. BCBSAZ Advantage will not be responsible for lost or
returned mail if we do not receive this form from the provider sixty (60) days prior to the effective date of the change. In addition, we recommend that the provider
submit a change of address form through the post office.
(Please complete all applicable information)
Phone/Address Change
Provider Change
Tax ID Change
NPI
Name Change
Other
PROVIDER
NAME and
(Last)
(First)
(MI)
Degree (MD, DO, etc.)
DEGREE:
Delete
Y
N
____ /_____ / _____
SSN
DOB:
Gender
M
F
Add
Y
N
mm
/
dd
/
yyyy
Current Name
New Name
Effective Date of Change
____/______/____
NAME CHANGE
Last
First
MI
Degree
Last
First
MI
Degree
GROUP NAME:
Group Practice Name (DBA): _________________________________________________________
(If applicable, may be used
as a “pay to” for claims
Group/Organization NPI :_______________________________ Effective Date:_______/_______/______
processing)
INDIVIDUAL NPI:
Individual NPI: _______________________________________ Effective Date:_______/_______/______
(Required)
TAX ID:
Existing Tax ID #: ___ ___-___ ___ ___ ___ ___ ___ ___
(Effective and
Add New Tax ID #:
___ ___-___ ___ ___ ___ ___ ___
Effective Date of Change:
___ __/______/___ __
termination dates
required for processing)
Terminate Tax ID #: ___ ___-___ ___ ___ ___ ___ ___ Termination Date: ___ __/___ __/___ ___
Termination Reason:______________________________________________________________________
PRIMARY PHONE /
___ ___/___ ___/___ ___
Effective Date of Change
ADDRESS:
(Physical location where
PHONE: (
)______________________ Fax: (
)___________________
services are performed.)
Street Address:___________________________________________
Suite #
_________
City:________________________________State:___________Zip:__________________
Authorization/Referral Fax: (
)_________________
Office Hours:______________________________________________________________
BUSINESS Email:
Email: ______________________________________________________________
(Not personal Email)
BUSINESS Website:
Website:_____________________________________________________________
SPECIALTY
Check applicable box:
Hospital Based
Office Based
(What specialty are you
actively practicing?)
Primary: ____________________________________________Board Certified
Y
N
Secondary:__________________________________________ Board Certified
Y
N
Individual Taxonomy:______________________
ARE YOU ACCEPTING NEW PATIENTS?
Y
N
–
Revision date 08/25/14
Blue Cross Blue Shield of Arizona Advantage
An independent licensee of Blue Cross and Blue Shield Association
1
ID ADV_330_2015
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