Application For Legal Status Change - Bcbsnm
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4Guide to Making Changes to Your Legal Status
Follow the instructions below if you are currently a participating Blue Cross and Blue Shield of
New Mexico provider, but need to make changes to your legal status such as:
Name
Tax Identification Number
o Moving from one group to another
o Move from a group practice to an individual practice (or vice versa)
1. Fill out the
Application for Legal Status Change
form below.
2. Send the completed form and accompanying documentation to the address listed at the
bottom of the form:
Blue Cross and Blue Shield of New Mexico
Network Services (HQ3)
P.O. Box 27630
Albuquerque, New Mexico 87125-7630
You can also fax the information to 1-866-290-7718 or 505-816-2688. For questions on how to
fill out the forms, call Network Services at 1-800-567-8540 or 505-837-8800.
3. If a provider is not accepted, a letter is sent informing you that you cannot be added at this
time based on the required criteria of the business needs.
Note: if you are changing or adding a new specialty or changing to become a PCP, please
complete the
Application for Provider Participation
form.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
(REV 03/08/10)
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