OK BCBS Group/Clinic Provider Enrollment Form free printable template

Group/Clinic Provider Enrollment Form SUBMITTER INFORMATION NOTE FIELDS MARKED WITH ARE REQUIRED. First Name Middle Initial Last Name Suffix Email Address Telephone Number Job Title/ Position Network Participation choose one Participate in-network Participate out-of-network Completing the form for Contract as Group/Clinic Provider GROUP PRACTICE INFORMATION Group Practice Name Type 2 NPI Organization Tax Identification Number TIN Group Website URL A Division of Health Care Service Corporation...

How to fill out clinic provider form

How to fill out OK BCBS Group/Clinic Provider Enrollment Form

1. Obtain the OK BCBS Group/Clinic Provider Enrollment Form from the official Oklahoma Blue Cross Blue Shield website or your local BCBS office.
2. Fill in the provider's legal name and any trade names in the appropriate sections.
3. Provide the provider's National Provider Identifier (NPI) number.
4. Complete the contact information, including address, phone number, and email.
5. Indicate the type of provider (e.g., individual clinician, group practice, clinic).
6. Include additional information like tax identification number (TIN) and banking information for electronic payments.
7. Review the enrollment form for accuracy and completeness.
8. Sign and date the form to certify the information provided is true and correct.
9. Submit the completed form as per the submission instructions provided.

Who needs OK BCBS Group/Clinic Provider Enrollment Form?

1. Any healthcare provider, group practice, or clinic that wishes to participate in the Oklahoma Blue Cross Blue Shield network and provide services to BCBS members.

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What is OK BCBS Group/Clinic Provider Enrollment Form?

The OK BCBS Group/Clinic Provider Enrollment Form is a document used by healthcare providers to enroll in the Blue Cross Blue Shield (BCBS) network in Oklahoma, allowing them to deliver services to members.

Who is required to file OK BCBS Group/Clinic Provider Enrollment Form?

Healthcare providers, including groups and clinics, who aim to contract with OK BCBS to provide services to their members are required to file this enrollment form.

How to fill out OK BCBS Group/Clinic Provider Enrollment Form?

To fill out the OK BCBS Group/Clinic Provider Enrollment Form, providers must complete all required fields accurately, provide necessary documentation, and submit the form to the appropriate BCBS department for processing.

What is the purpose of OK BCBS Group/Clinic Provider Enrollment Form?

The purpose of the OK BCBS Group/Clinic Provider Enrollment Form is to formally register healthcare providers with Blue Cross Blue Shield of Oklahoma, ensuring they are authorized to provide covered services to members.

What information must be reported on OK BCBS Group/Clinic Provider Enrollment Form?

The form requires information such as provider identification details, practice location, taxation details, contact information, and credentials to verify the provider's qualifications and compliance with BCBS standards.