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Mail to:

Fax:

P.O. Box 186

(802) 371-3489

Email:

Montpelier, VT 05601-0186

Instructions for Completing the

Group/Independent Practice Enrollment/Change Form

Complete each section as it pertains. This form will be returned unprocessed if information or signature is missing.

If you have any questions on how to complete this form, please call (888) 449-0443, option 2. Mail completed form to

the address above or fax to the number above. Note: For complete enrollment and credentialing requirements, refer to the

Provider Manual online at

Reason for Form

• Add New Group Practice—Adding a new group practice, complete all sections

Check the box(s) next to

of this form. Effective date is subject to contracting and credentialing dates.

the action

• I Intend to Contract—Contacts have been signed and returned with

this completed form. This is a participating group practice.

you are requesting.

• I Do Not Intend to Contract—Contacts are not included with this completed form.

This is a non-participating group practice.

• Physical Address and/or Phone Number Change—Used to update a physical location

• Payment Address or Phone Changes —Used to update the payment address.

• Correspondence Address Change—Used to update the correspondence address.

• Change Group Tax ID- A new W-9 or SS-4 is required.

• Change Group Name– A new W-9 or SS-4 is required.

• Change Group NPI Number—Used to update an NPI number.

Please indicate a future effective date.

• Other—Used for any other changes to the group practice that are not already listed.

Office Information • Group Practice Name—This is the name used to file taxes with the federal government.

This name has to be consistent on all documents, including contracts and the W-9.

Note: To ensure proper reimbursement in accordance with federal regulations, the

group practice name provided in the business address section must be identical to

that which is associated with the Tax ID Number used to report BCBSVT reimbursement.

Failure to provide the proper business name may result in inaccurate reporting to the IRS.

• Group Practice National Provider Identifier (NPI Number)—The number assigned to

the practice by the Federal Government.

• Taxonomy Code—List the taxonomy code associated with your NPI Number.

• Group Practice Office Hours—The hours that the practice is open and seeing patients.

• Group Practice Website—List any web addresses that the practice has online.

• Physical Location and Phone Number—Physical address where services are rendered

and listed in the directory. Complete a separate form (Section 2 only) for each additional

location.

• Payment Address and Phone Number—Address for remittance and payment only.

If you use a third-party billing service, please provide written authorization for

BCBSVT to communicate directly with the billing service.

• Correspondence Address—To be used for all mailings except payments. Including but

not limited to assignment agreements, contractual amendments, general information

and updates.

• Tax ID Number—As listed on the W-9 or the IRS SS-4 form.

Enrollment Contact

• Contact Name—Name of the person responsible for provider enrollment and

Information and

credentialing.

Authorization

• Contact Phone Number—Phone number to contact the enrollment person.

• Contact E-mail Address—E-mail address of the contact enrollment person.

•

Authorized Signature and Date Required—Signature of the person with the

authority to associate the new provider to the group practice contract.

Group/independent Practice Enrollment/change Form (Gpecf) - Blue Cross Blue Shield Of Vermont Page 2

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