Blue Cross Blue Shield of Illinois - Request Demographic Information Changes

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Request Demographic Information Changes

Reminders:

You may specify more than one change within your request when all changes relate to the same billing (Type 2) NPI. Changes involving multiple billing NPIs and/or multiple providers within a group must be requested on a spreadsheet, rather than via this online form.
Changes are not immediate upon submission of this form. Processing may take up to 15 business days. Note: the Provider Finder^Â® may take up to 30 days to reflect the change.

*Required Field

*Step 1: Type(s) of Change:

Please Check All That Apply:

Change Existing Provider/Group Name
Change Existing Payee/Billing Location Information
Change Existing Office/Physical Location Information
Add Additional Office/Physical Location

Change Existing NPI [Type1 and Type2]
Change Existing Tax ID Number
Change/Add Hospital Affiliation(s)

*Explanation of Changes(s):

*Step 2: Your Current Information:
[Identification information already on file with BCBSIL]

Legal Name of Provider/Group:

Practice Name:

Telephone Number:

Fax Number:

E-mail Address:

Type 1 [Individual] NPI:
(If applicable, must be 10 digits)

Type 2 [Organizational] NPI:
(If applicable, must be 10 digits)

Tax ID Number:
(Must be 9 digits)

Contact Name and Title:

Contact Telephone Number:

*Step 3: Your New Information
[Changes that need to be made to your existing file]

Provider/Group Name Change
[Individual Provider or Practice Name change]

New Name:

Payee/Billing Location Change
[This information does NOT appear in the BCBSIL Provider Finder^®]

Address 1:

Address 2:

City:

State:

Zip:

Telephone Number:

Fax Number:

E-mail:

Office/Physical Location Change
[Medical office information that members may use to contact you]

Address 1:

Address 2:

City:

State:

Zip:

Telephone Number:

Fax Number:

E-mail:

Add Additional Office/Physical Location:

Address 1:

Address 2:

City:

State:

Zip:

Telephone Number:

Fax Number:

E-mail:

NPI

Type 2 NPI [Organizational]:
(Must be 10 digits)

Type 1 NPI [Individual]:
(Must be 10 digits)

New Tax ID Number

New Tax ID Number:
(Must be 9 digits)

Hospital Affiliation(s)

Primary Hospital Name and City:
[Example: ABC Hospital, Chicago, IL]:

*Step 4: Attestation

Attestation: I hereby certify that the information submitted within this form is accurate and complete.