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Online Registration
HMO Administrative Forum Workshop - Half Day
December 10, 2008
*
Are you a...
BCBSIL Provider
Billing Agency
*
Provider/Billing Agency Name:
*
Provider Number(s):
Billing Agencies must list all numbers
NPI Number:
Please bring a copy of the NPPES confirmation letter or email
*
Address:
City/
*State/*Zip Code
/
/
*
Telephone Number:
/
/
*
Fax Number:
/
/
*
E-mail Address:
*Number of Attendees:
*Name(s) of Attendees
Are you a...
(choose all that apply)
Physician
Administrative Office Staff
*
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
*
Indicates a required field
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
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