Transcription of Instructions for fax cover sheet
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Instructions for fax cover sheet
WF 10579 SEP 18 Page 1 of 8 Questions? Call 1-800-822-27612. Fax the registration form and attachments ( , signature documents) to1-866-900-0250. Be sure to fax the registration information separately foreach provider. (For example: If you register two or more providers, you mustsend a fax for each provider. They cannot be bundled into one faxtransmission.) cover sheet must be the first page of your form for document submissionFrom (Insert name of contact person) Date (MM/DD/YYYY)Type 2 NPI National Provider Identifier Tax identification (Insert name of contact person) Date (MM/DD/YYYY)Type 2 NPI National Provider Identifier Tax identification numberInstructions for fax cover sheetWe cannot accept handwritten forms. Do not hand write anywhere on the form, otherwise processing will be individual (Insert name of contact person)Date (MM/DD/YYYY)Type 1 NPI National Provider IdentifierState license numberWhen adding an individual to an existing group, be sure to fax a group change allied professional group practices and License Number:Form Number:PRACTITIONER CHANGE FORMMail to:Provider Enrollment - C334 Blue Cross Blue Shield of Michigan Box 217 South ield, MI 48034 Date:From:Fax To: 866-900-0250 Provider EnrollmentIMPORTANT: Attach this page to the top of your document toavoid processing cover SH
Independent Physical Therapist Independent Occupational Therapist Independent Speech Language Pathologist Section 4: Termination of networks Note: If you are terminating all networks, please complete the Practitioner Termination Form. Requested termination date - The actual date of your termination will be determined based on the
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