Provider Information Update Form – Fill Out and Use This PDF

MAIL TO: BLUE CROSS AND BLUE SHIELD OF FLORIDA

Provider Information Update Form

Use this form to update your provider information (e.g., service location, payment address, tax identification number) with Blue Cross and Blue Shield of Florida. Please complete all of Section I and only the information that is changing in Sections II–VIII. Providing complete and legible information will expedite your request and help ensure accurate processing. Mail or fax the completed form to the address and number indicated above.

Section I: Provider Information - Complete all fields below in Section I

*Legal documentation (e.g., marriage license) is required for changes to last name

Note: For Sections II–VIII, complete only the section(s) that requires a change.

Section II: Languages Spoken

List non-English languages spoken by provider and/or staff in order of fluency. (If language is spoken by staff only, please check “Staff” box.)

Section IV: Office Hours

Office Hours

Section V: Payment/Billing Address

A signature at the bottom of this form by the Tax ID owner is required for all payment address changes.

Section VI: Tax Identification/Employer Identification Number (TIN/EIN)

In order to update your Tax ID, a completed W-9 must be attached to this form.

Section VII: Hospital Affiliation Update

A hospital privilege letter from the facility along with written notification from the provider’s office (administrator, manager, provider, etc.) and/or attestation form for hospital-based physicians is required.

Section VIII: Professional Association Deletion

Note: A Billing Authorization for Professional Associations (PA) Form must be completed when adding a provider to a group. A PA Form along with an attestation form is needed for hospital-based providers.

Additional Comments

For Internal Use Only: Provider Number ___________