Request Addition of Provider to Group

Reminders:

  • 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 a letter to the group once complete. 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.
  • Due to the credentialing requirements, Changes are not immediate upon submission of this form. The provider being added to the group will not be considered in network until they are appointed into the network. Processing can take 30-120 days. BCBSIL will review and send a letter to the group once complete.
*Indicates a required field.
 
*Step 1: Your Current Group Information
[Group's identification information already on file with BCBSIL]
Group Name:
Group Tax ID:
(Must be 9 digits)
Group Type 2 NPI:
(Must be 10 digits)
Contact Name and Title:
Contact Telephone Number:
Contact E-mail Address:

Step 2: New Provider Information
Add a Provider to Your Group
[The following information is needed to add a provider to your group.]
Individual Provider Name:
CAQH #
Date of Birth:   
Provider's Gender: Male
Female
Specialty:
Specialty Certification Date:   
IL License Number:
Individual's Type 1 NPI:
(Must be 10 digits)
DEA #:
DEA # Expiration Date:   
Board Certified: Yes
No
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):
Address 1:
(Where the provider will see patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:

Add a New Office Location to Your Group
[The following information is needed to add a new office location to your group.]

Group Name:

Specialty:
Group Type 2 NPI:
(Must be 10 digits)
Address 1:
(Where the provider will see patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:

*Step 3: Attestation
Attestation: I hereby certify that the information submitted within this form is accurate and complete.
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