Anthem Physician Data Sheet 2009-2025 free printable template

Provider Data Form For Notification Purposes to Anthem BCBS Date Completing: Group Name: Group NPI: Primary Office Street Address: (please include PO Box if required for mailing purposes) Group Tax

How to fill out Anformm Physician Data Sheet

How to fill out Anthem Physician Data Sheet

1. Begin with the physician's personal information: Name, NPI number, contact information.
2. Provide details about the practice location and mailing address.
3. Indicate the specialties and subspecialties of the physician.
4. Fill in education and training history, including medical school and residency.
5. List any board certifications and professional affiliations.
6. Complete sections regarding insurance participation and any contracted networks.
7. Review and verify all entered information for accuracy.
8. Sign and date the document before submission.

Who needs Anthem Physician Data Sheet?

1. Any physician or healthcare provider seeking to join or work with Anthem's network.
2. Practices that need to update their provider information with Anthem.
3. Physicians looking to ensure their data is accurate for claim processing and patient referrals.

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What is Anthem Physician Data Sheet?

The Anthem Physician Data Sheet is a form used to collect and verify information about healthcare providers to ensure compliance with Anthem's credentialing standards.

Who is required to file Anthem Physician Data Sheet?

Healthcare providers seeking to join or maintain their status in the Anthem network are required to file the Anthem Physician Data Sheet.

How to fill out Anthem Physician Data Sheet?

To fill out the Anthem Physician Data Sheet, providers must accurately provide their personal, professional, and educational information, including licenses, certifications, and work history as required by the form.

What is the purpose of Anthem Physician Data Sheet?

The purpose of the Anthem Physician Data Sheet is to facilitate the credentialing process, ensure providers meet network requirements, and maintain up-to-date information for patient care and quality assurance.

What information must be reported on Anthem Physician Data Sheet?

Information required on the Anthem Physician Data Sheet typically includes personal identification details, practice locations, specialty, education, training, licensure information, and any malpractice history.