Looking for a Bcbs Forms And Templates? Download it for free!

Mail to:

P.O. Box 186

Fax:

(802) 371-3489

Email:

Montpelier, VT 05601-0186

Group/Independent Practice Enrollment/Change Form (GPECF)

Section 1: Reason for Form

… Add New Group Practice (Date) _____________________

… Payment Address and/ or Phone Number Change

… I Intend to Contract

… Correspondence Address Change

… Change Group Tax ID Number (W-9 Required)

… I Do Not Intend to Contract

… Change Group Name (W-9 Required)

… Physical Address and/or Phone Number Change

… Change Group NPI Number

… New

… Other _________________________________________

… Moved (Old Address) ___________________________

Date of Changes _______________________________

…

_____________________________________________

Date of Changes _______________________________

…

Section 2: Office Information

Group Practice Name _______________________________________________________________________________

Group Practice NPI Number _______________________________ Taxonomy Code ___________________________

Group Practice Office Hours________________

Group Practice Website_____________________________________

Are you a HCFA (Health Care Financing Adminstration) or UB (Universal Billing) billing practice?___________________

Are you an Urgent Care Center? Yes____ No____

Are you an ECP (Essential Community Provider) Provider? Yes____ No____

Physical Address

________________________________________________________________________________________________________

Street

___________________________________________________________________________

City

State

ZIP

___________________________________________________________________________

Phone Number

FAX Number

Payment Address

________________________________________________________________________________________________________

Street

___________________________________________________________________________

City

State

ZIP

___________________________________________________________________________

Phone Number

FAX Number

Correspondence Address

_________________________________________________________________________________________________________

Street

___________________________________________________________________________

City

State

ZIP

Tax ID Number

_________________________________________________________________________________________________________

(W-9 or IRS SS-4 form required for new practices only. See instructions please.)

Section 3: Authorization and Contact Information

Contact Name (Please print) __________________________________________________________________________

Contact Phone Number _____________________________________________________________________________

Contact E-mail Address _____________________________________________________________________________

I certify that the above information is complete and accurate, and I agree, if a new provider is enrolling with this group, that the services the provider renders to

Blue Cross and Blue Shield of Vermont (BCBSVT) members and members of BCBSVT’s licensed affiliates will be provided according to the terms and conditions of the

professional provider group contract, the physician-hospital organization contract, or the hospital contract (if provider is employed or contracted with a hospital),

whichever is applicable, between such entity and BCBSVT and/or BCBSVT affiliate.

Authorized Signature _______________________________________________ Date __________________________

284.328 (6/2014)