Form 9101 - Highmark Provider Form - Blue Cross Of Northeastern Pennsylvania
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1
2
3Highmark Provider Form
Please read the instructions below before completing this form, and mark a box for each action taken.
ALL requests must complete Sections 1 and 6.
Adding or deleting a provider? Complete Sections 1, 2, 3 and 6.
Changing a main/practice/check/mailing address? Complete Sections 1, 3 and 6.
Changing a group name/DBA name/Tax ID? Complete Sections 1, 5 and 6.
Creating an Assignment Account (PA) or Pay-To Account (WV)? Complete Sections 1, 2, 3, 4, and 6.
SECTION 1 – Please complete for all requests.
Name of Account (DBA name)
Tax ID
(Provide copy of Federal IRS Notification. W-9 is NOT acceptable.)
Type 2 (Group) National Provider Identifier (NPI)
Highmark Group Number
SECTION 2 – Please complete if adding or deleting a practitioner. (Note: For NaviNet users, changes should be made online.)
Effective date of addition/change
If a practitioner needs to be credentialed, log on to the Provider Resource Center at
under
"Provider Applications" and complete the "CAQH ID Request" to start the process.
Practitioner Name
Date of
CAQH ID
Type I NPI (Individual)
Practitioner Specialty
Add Delete
Birth
SECTION 3 – Please complete for address changes or additions. (Note: For NaviNet users, changes should be made online.)
Add Change Main Practice address
Add* Change Delete Practice address(es)
Effective date of addition/change
Add Change Check address
Add Change Mailing address
Main Practice Address – Primary physical practice location (PO Box numbers are NOT acceptable)
Practitioners at this location:
Telephone number:
(
)
Member Access Number:
(Patients call this number to make an
(
)
Fax number: (
)
appointment for this location)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Office hours
Practice Address 1 -
Practitioners at this location:
physical location where patients receive services
Telephone number: (
)
Fax number: (
)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Office hours
Practice Address 2 -
Practitioners at this location:
physical location where patients receive services
Telephone number: (
)
Fax number: (
)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Office hours
* Use a separate sheet for additional practice addresses.
Mailing Address –
Check Address –
if different than Main Practice and Check Address
where checks are sent
Is this a lockbox? Yes No
Telephone number: (
)
Telephone number: (
)
Fax number:
(
)
Fax number:
(
)
9101 (R12-11)
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