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Provider Enrollment Form - bcbswny.com

Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. R13368-B_Provider Enrollment form Rev 10/1/21 Provider Enrollment form Please fax the completed form to (716) 887-2056, along with your Certificate of Liability Insurance. Thank you for your interest in becoming a participating Provider with Highmark Blue Cross Blue Shield of Western New York. Please complete all information requested on this Enrollment form . The information provided must match your CAQH application; incomplete forms or forms that do not match CAQH will be returned. The CAQH application must be completed and re-attested with authorization to Highmark BCBSWNY to access the application.

R13368-B_Provider Enrollment Form Rev 10/1/21 . Provider Enrollment Form . Please fax the completed form to (716) 887-2056, along with your Certificate of Liability Insurance. Thank you for your interest in becoming a participating provider with Highmark Blue Cross Blue Shield of Western New York. Please complete all information requested on ...

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