The Anthem W 9 form identifies temporary physicians joining the Anthem Blue Cross and Blue Shield network in Maine. Providers must hold a Maine permanent license and agree to serve for less than six months before applying for temporary participation.
The form collects your legal name, any business or trade name, your address, and your federal tax classification. It also requires your taxpayer identification number, which Anthem uses to process claims payments and issue annual 1099 tax forms. Providing an accurate TIN prevents backup withholding on your payments.
Submit the Anthem W 9 form alongside the following documents. Missing any item delays the effective date of your temporary participation.
Send your completed packet by fax or certified mail to the Anthem Provider Service team. Anthem will review your documents and confirm an effective date of service in writing. Do not begin providing services until you receive written confirmation from Anthem, because retroactive credentialing is not permitted under the temporary participation program.
Applications are most often rejected because of a mismatched TIN, a missing attachment, or an expired license. Double-check every document before submitting. If Anthem receives an incomplete packet, it returns the entire package and requires a full resubmission from the start.
Need other provider forms? See the Anthem Blue Cross application form, the substitute W-9 form, or the CAQH provider application for full network enrollment paperwork.
| Question | Answer |
|---|---|
| Form Name | Anthem W 9 Form |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | Anthem substitute W-9, Anthem Blue Cross W-9, Anthem BCBS W-9 |