Request To Establish Or Revise A Non-Contracted Provider Record

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P.O. Box 27630
ATTN: Network Services
Albuquerque, NM 87125-7630
Fax: (505) 816-2688 or 1-866-290-7718
Request to Establish or Revise a Non-Contracted Provider Record
Please check one:
Establishing a new provider record
Revising an existing provider record
Please provide your name, any information that you
Please complete the entire form.
wish to change, and your signature.
NOTE: If this is a group practice, please complete a separate form for each individual.
Provider Name (Title/Degree): ___________________________________________________________________
Social Security #: _____________________________________ Date of Birth: __________________________
Federal Tax ID # (TIN or EIN): ___________________________
(If TIN change, effective date of new TIN)__________________
*Type 1 Individual NPI (National Provider Identifier) #: _______________________
Business or Group Name: ______________________________________ Type 2 NPI# _____________________
____________________________
*Effective date of joining group:
Your license indicates you are certified as: _________________________________________________________
License #: _______________________ State: ____________________
Primary Specialty: ______________________________________________
Secondary Specialty: ____________________________________________
Physical Address: ___________________________________________________________________________
City, State, Zip: _______________________________________________ *Effective Date: __________________
Phone: ___________________________________________ Fax: _____________________________________
Note: Please attach a separate sheet for any additional locations.
Mailing Address:
Business or Group Name: ______________________________________________________________________
Street Name: ________________________________________________________________________________
City, State, Zip: ______________________________________________
Phone: ___________________________________________ Fax: _____________________________________
Billing Address:
Business or Group Name: _____________________________________ Type 2 NPI #: _____________________
Street Name: ________________________________________________________________________________
City, State, Zip: ______________________________________________
Phone: ___________________________________________ Fax: _____________________________________
*Make Payment Payable to: ____________________________________________________________________
*Federal Tax ID # _____________________ *IRS Legal Entity Name: __________________________________
Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) must be reported exactly as recorded with
the IRS. Please complete and return the IRS 147C letter with this questionnaire.
Signature of person completing this form
Date
Phone No.
*REQUIRED FIELDS
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.
April 2013

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