Professional Secured Access Application - BCBSM

Provider Secured Access Application FAX COVER PAGEFax To: From (office):Date: DEC 20 We cannot accept handwritten forms. Do not hand write anywhere on the forms(except for the signature), otherwiseprocessing will be delayed. To ensure forms are processed timely, please adhere to the following instructions :oEnter all information online(Google Chrome or Internet Explorer work best).oPress the tab key after each entry to move from field to re always looking for ways to protect our member s information and keep your account secure. That s why we d like to connect your online account to an email address that s related to your business rather than a public email provider such as Hotmail, Gmail or Yahoo.

I herebystatethe information provided on this application is correct and the provider/facilityNPI(s) listed pertain to the facilityonly. Signer's title If the office does not have access to Provider Secured Services, submit a Use and Protection Agreement with this application. Facility/Practice Name (Provider Name) Section 6.

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  Applications, Access, Secured, Secured access application

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