Professional Secured Access Application

1 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.

2 If you have a company email address, please include it on your request for Access or changes to your Provider Secured Services account at If you re not sure whether a company email address is available to you, check with your website administrator. Most websites offer a domain email free with your account. If you re a smaller practice that doesn t host a website, we ll accept your request with the email you use to conduct your NOTE!!**ATTENTION**Contact:Provider Secured Access ApplicationUsers cannot take their assigned IDs to other organizations. Please complete electronicallyFacility/Office Practice Name (where users are located) Provider Specialty Street Address and Suite Number (address where users are located) Contact Person City State Zip Code Tax ID: Contact Person's Telephone and ExtensionContact Person's company issued email address Company issued email address to receive assigned Provider Secured Services ID(s):Section 3.

3 For offices that currently have Access to e-referral and are requesting Access for additional users, provide the Set ID or a User ID from office in Section 1. Set/User ID Section 4. To view an example of a specific required code, place the mouse pointer in the center of the input field. Assigned NPI Number(s) Section 5. BCN HMO and/or BCBSM Physicians BCN Physician Organization For individual providers, enter the Michigan state license number(s). Enter the BCN IH Code(s) BCBSM Physician Organization Name/ Identifier(s) To obtain Secured Access user IDs, complete page 2 of this form.

4 1 WF 15607 DEC 20 For Health e-Blue Access , select the applicable network(s) below. Please note - Requesting Health e-Blue will add additional processing time Section 2. Please add all NPIs from this existing User ID for the features requested by new user(s) in section 6. ID must be from office listed in Section 1. NPIs listed below in Section 4 are for new Access for Provider Secured Services and e-referral. All users receiving Claims Tracking & EFT Access will automatically receive Access to e-Referral. To add NPI(s) to an existing e-referral set ID - submit the e-referral Request for Group ID Changes.

5 ( ) If additional space is needed, attach a separate listing of IDCheck box if company issued email address is 1. I hereby state the information provided on this Application is correct and the provider/facility NPI(s) listed pertain to the facility only. 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. Check ONLY the requested features for each user, if no features are selected the user will receive eligibility only (Type in full legal name for each user) MANDATORY MANDATORY Claims Tracking, EFT BCN PCP Claims Summary Health e- Blue (HEB)Assigned Provider Secured Service ID (If BCBSM has assigned the user an ID) Example: John Doe 248- 222- 1111X X X Example: F###### Section 7.

6 Mandatory Authorization for use and Access I hereby state the information provided on this Application is correct and the provider NPI(s) listed pertain to the provider only Date Type name of the authorized signer Signer's title If there are questions, call 1-877-258-3932. Hours of operation: Monday-Friday 8 am-8 pm To the extent you are applying for Access as a provider, all confidentiality provisions contained in your Participating Hospital Agreement/Hospital Affiliation Agreement are applicable to every individual user granted Secured Access by this Application .

7 I understand by signing this Application I agree to only use and/or disclose BCN/BCBSM patient data for permissible treatment, payment and healthcare operation activities that allow me to service and care for my Blues patients. I also further agree that I will only use and/or disclose Medicare Advantage data to service and care for my Medicare Advantage patients. By signing above, I represent that I am a Provider or the Authorized Representative and warrant that I have been granted full legal authority by corporate resolution, appropriate delegated signature authority, or as permitted by a signature policy, to enter into and bind the provider and/or provider group to contracts and agreements and intending to be legally bound have executed this agreement on the date above.

8 I addition, I understand that by signing above I have the company s designated authority to request and maintain minimum necessary web Access and am responsible for complying with all terms and conditions contained within the Provider Secured Services Use and Protection Fax Application to 1-800-4 95-0 812 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 2 WF 15607 DEC 20 Provider authorized signatureHandwritten signature only. Provider Secured Access Application Users cannot take the assigned IDs to other organizations.

9 Please complete electronically 1. additional space is needed, attach and sign additional page 2 (sections 6 & 7).X User's Business Telephone Number e- referralADDENDUM "G" Practice or Facility Name Contact Person Street Address and Suite Number Contact Person's Telephone and Extension City State Zip Code Contact Person's company issued email address Provider Group Name Type 2 NPI(s) Provider Enrollment and Change Self -Service Access Request Name (Type or Print Full Name of Each User) Telephone Number Provider Secured Services ID Provider Enrollment and Change Self -Service Basic Access Provider Enrollment and Change Self -Service Full Access John Doe 111-222-3333F000000 Provider Enrollment and Change Self -Service Authorization By signing below, I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority to enter into and bind my provider group to agreements.

10 I understand, acknowledge, and attest that the user(s) listed on this Addendum have the authority to perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals. Note: This is an Addendum to the Provider Secured Services Use and Protection Agreement and does not alter the terms set forth therein. Name of Authorized Group Representative Title of Authorized Group Representative Signature of Authorized Group Representative Handwritten signature only Date Please complete electronicallyAuthorization for Provider Enrollment and Change Self-Service WF 16643 DEC 201 Section 1.