Blue Cross Blue Shield of Illinois

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Select Workshop: Harvest the Rewards of Education Workshop October 29, 2008, St. Elizabeth's Hospital, 211 S. 3rd Street, Belleville, IL 62220, Millennium Conference Room New Provider Workshop November 12, 2008, BCBSIL 300 East Randolph, Chicago, IL 60601, CAL Auditorium
*Are you a...	BCBSIL Provider Please indicate below: Physician Administrative Office Staff Billing Agency Please indicate submitter ID below:
*Provider/Billing Agency Name:
Provider Number(s): Billing Agencies must list all numbers*	Type 1(Individual) Type 2(Organizational)
NPI Number(s): Please bring a copy of the NPPES confirmation letter or email.	Type 1(Individual) Type 2(Organizational)
*Address:
City/State/*Zip Code:	/ /
*Telephone Number:	/ /
*Fax Number:	/ /
*E-mail Address:
*Number of Attendees:
*Name(s) of Attendees
How do you submit claims? (choose only one)*	Electronic Paper
What Products do you currently have contracts with: (choose all that apply)	PPO BlueChoice HMO
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