Provider Information Update Form – Fill Out and Use

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

Provider’s Full Name* (last, first, middle initial/business name)			Title
BCBSF Provider Number	Individual NPI		Organizational NPI
Medicare Number	Medical/DOH License Number		Social Security Number/Tax ID
Specialty			Effective Date of Request (MM/DD/YYYY)
Office Contact Name	Telephone Number (for appointments)		Email Address
	(	)

*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.)

Previous						New	Office Location		Hospital Based Location
						Other (independent diagnostic center, supplier, etc.)
Street Address						Street Address
City			State		Zip	City			State		Zip
Telephone Number		Fax Number				Telephone Number		Fax Number
(	)	(		)		(	)	(		)
Email Address						Email Address

Section IV: Office Hours

Office Hours

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
A.M.
P.M.

900-502-0511

May 2011

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.

Previous					New
Provider Name (last, first, middle initial/business name)					Provider Name (last, first, middle initial/business name)
Street Address					Street Address
City			State	Zip	City			State		Zip
Telephone Number		Fax Number			Telephone Number		Fax Number
(	)	(	)		(	)	(		)
Email Address					Email Address

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.

	Hospital Name	Hospital BCBSF	Hospital NPI	Add/Delete?	Effective/
		Provider Number			Expiration Date
	(1)			Add
				Delete
	(2)			Add
				Delete

Section VIII: Professional Association Deletion

Print Name of		Signature of
Physician/Provider		Physician/Provider

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

Print Name ________________________________	Signature _____________________________________
Title ______________________________________	Date _________________________________________
900-502-0511	May 2011

For Internal Use Only: Provider Number ___________