Provider Enrollment/change Form (Pecf) - Blue Cross Blue Shield Of Vermont
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1
2Mail to:
Fax:
P.O. Box 186
(802) 371-3489
Email:
Montpelier, VT 05601-0186
Provider Enrollment/Change Form (PECF)
Section 1: Reason for Form
… Add Provider (Date) _________________________
… Accepting New Patients
… Terminate Provider (Date) ____________________
… Not Accepting New Patients
… Age Restriction
If a primary care physician (PCP) is “terminating, ”
… Location Change:
Add
Terminate
indicate the name of the PCP accepting their
… Comments _________________________________
patient panel. _____________________________
… Provider Name Change (Attach copy of license.)
Section 2: Office Information
Group Practice Name _______________________________________________________________________________
Group NPI Number ______________________________ Tax ID Number _____________________________________
(W-9 not required for existing groups)
Is this location part of Vermont Blueprint for Health?
Yes
No
Is this location
Primary?
Secondary?
Provider Physical Location ___________________________________________________________________________
Street
___________________________________________________________________________
City
State
ZIP
___________________________________________________________________________
Phone Number
FAX Number
Section 3: Provider Information
Provider NPI Number ____________________________ Taxonomy Code ____________________________________
Provider CAQH Number __________________________
Provider Name ____________________________________________________________________________________
First Name
Middle Initial
Last
Degree
Date of Birth ___________________________________ Social Security Number ______________________________
Gender
M
F License Number _____________________________ DEA Number _______________________
(Please include copy)
(Please include copy)
Hospital Affiliation(s) ____________________________ Languages Spoken _________________________________
… Primary Care Physician Accepting patients
Yes
No Cross covering only
Specialty __________________________ Sub-specialty____________________________
… Specialist Specialty ________________ Sub-specialty ___________________
… Locum Tenens
Hospitalist Provider
(Six months maximum length of service)
(Credentialing required)
… Per Diem
(Credentialing required)
Start Date_____________ End Date______________
Section 4: Authorization and Contact Information
Contact Name _____________________________________________________________________________________
Contact Phone Number/ E-mail Address _________________________________________________________________
I certify that the above information is complete and accurate, and I agree, if a new provider is enrolling on this form, 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 __________________________
284.329 (6/2012)
*PECF*
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