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.
  • Legal Name Change Request you must complete a new contract and application to initiate a name change. Complete the online application request form.
  • To request multiple changes of one or more billing NPI numbers (Type 2), or rendering providers NPI (Type 1), send a request to netops_provider_update@bcbsil.com. BCBSIL will review and send all affiliated providers and service locations listed under your Tax ID number to the email address provided. It is extremely important that you verify the accuracy of the data we have on file and provide exact service locations and affiliated providers to be added to the BCBSIL files.
  • Changes are not immediate upon submission of this form.
  • Processing may take up to 30 business days.
  • Note: the Provider Finder® may take up to an additional 30 days to reflect the change.

*Indicates a required field

Step 1: Your Current Information
[Identification information you should have on file with BCBSIL. Please complete this information if you have not already provided it.]
Rendering NPI:
(If applicable, must be 10 digits)
*Billing NPI:
(If applicable, must be 10 digits)
*Tax ID Number:
(Must be 9 digits)
*Contact Name and Title:
*Contact Telephone Number:
Legal Name of Provider/Group:
Date of Birth:   
Provider's Gender: Male
Female
DEA #:
DEA # Expiration Date:   
Board Certified: Yes
No
Specialty:
Specialty Certification Date:   
Languages (Spoken or Written):
Medical School Name:
Year of Graduation:   
Internship Hospital Name:
From:   
To:   
Residency Hospital Name:
From:   
To:   
Accepting New Patients: Yes
No

Hours of Operation:

Morning / All Day
  Open Hours Close Hours
Monday
Tuesday
Wednesday
Thursday
Friday
 
Afternoon
  Open Hours Close Hours
Monday
Tuesday
Wednesday
Thursday
Friday
 
Evening
  Open Hours Close Hours
Monday
Tuesday
Wednesday
Thursday
Friday
 
Weekend
  Open Hours Close Hours
Saturday
Sunday
 
Primary Hospital Affiliation (MD/DO Only ):
Practice Name:
Telephone Number:
Fax Number:
E-mail Address:

*Step 2: Type(s) of Change

Please Check All That Apply:

Changing or Adding Additional Billing NPI
Change Existing Payee/Billing Location Information
Change Existing Office/Physical Location Information
Change Existing Rendering NPI
Change Existing Tax ID Number
Change/Add Hospital Affiliation(s)
Other
*Explanation of Changes(s):

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:
NPI
Billing NPI:
(Must be 10 digits)
Rendering NPI:
(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]:

Other:

*Step 4: Attestation
Attestation: I hereby certify that the information submitted within this form is accurate and complete.
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