Bcbs Authorization Form For Clinic/group Billing
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Authorization Form for Clinic/Group Billing
Arkansas Blue Cross and Blue Shield • Health Advantage • USAble Corporation
:
New Clinic or Group
Add Practitioner to Existing Clinic/Group
Please check one
Name of Clinic or Group ______________________________________________________________________
Date Practitioner Joined Clinic or Group (MM/DD/YYYY) ____________ Clinic/Group EIN _________________
Clinic/Group Provider # (If already issued)_________________________________________________________
National Provider Identifier # ___________________________________________________________________
Practice Location Address of Clinic/Group ________________________________________________________
________________________________________________________________ County ___________________
Practice Phone # for Patient Appointments ______________________ Practice Fax # ___________________
Contact Person ____________________________________________ Phone # ________________________
Correspondence Address of Clinic/Group _________________________________________________________
________________________________________________________________ County ___________________
Correspondence Phone # ____________________________________ Correspondence Fax # _____________
Contact Person ____________________________________________ Phone # ________________________
Payment Name ____________________________________________ Payment EIN ____________________
(Attach IRS verification of EIN)
Payment Address of Clinic/Group _______________________________________________________________
________________________________________________________________ County ___________________
Payment Phone # __________________________________________ Payment Fax # ___________________
Contact Person ____________________________________________ Phone # ________________________
The undersigned hereby authorizes ___________________________ (clinic/group name) or any of its duly authorized
administrators, to accept on the undersigned’s behalf any assignment or direct payment for services rendered by undersigned
at such clinic/group that are covered under the following contracts:
Arkansas Blue Cross and Blue Shield Preferred Payment Plan
USAble Corporation Primary Care Network
USAble Corporation Arkansas' FirstSource® PPO
HMO Partners, Inc. (d/b/a Health Advantage)
USAble Corporation True Blue PPO
This authorization applies to all moneys due under the agreements designated above, including payment for healthcare
services and any risk-sharing settlements, if applicable.
The undersigned retains the right to revoke this authorization by giving 30 days prior written notice to Provider Network
Operations, Attention Clinic/Group Billing Authorization. The undersigned understands and agrees that the clinic/group
named above can likewise refuse to accept payment(s) authorized by this assignment. Payments for services rendered at
above named clinic and due after Provider Network Operations receives the written notice of revocation of this authorization
from the undersigned or refusal to accept payments from the clinic/group, shall be paid direct to undersigned, provided,
however, that the following additional terms shall apply: (a) following execution of this Authorization, neither Arkansas Blue
Cross and Blue Shield nor any other payer accessing the PPO or HMO networks (hereafter collectively referred to as
“Payers”) shall be obligated to redirect payment to any other location or recipient except upon 30 days’ prior written notice; (b)
Payers shall be entitled to require satisfactory proof of signatures and authority to redirect payment; (c) in the event of a
dispute between clinic/group and the undersigned or between the undersigned and any other party regarding right to receipt
of any payment, Payers may, in their sole discretion, either hold all payments until such Payers deem the dispute resolved, or
Payers may make payment to clinic/group, in which case the undersigned agrees to look solely to clinic/group with respect to
any claims for payment, and the undersigned hereby releases Payers from any liability with respect to such payments. By
signing this form, the undersigned expressly agrees to the preceding terms and conditions of clinic/group billing.
________________________________________________________________________ Provider # ____________________________
Print Name of Individual Practitioner
Signature ________________________________________________________________ Date _________________________________
(Individual Practitioner- NO STAMPS OR DIGITAL SIGNATURES)
(MM/DD/YYYY)
Provider Network Operations, P.O. Box 2181, Little Rock, AR 72203
Phone: 501-210-7050
Fax: 501-378-2465
FORM 108
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