Request Removal of Provider from 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 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 can take a minimum of 30 business days.
*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: Departing Provider Information
The following individual provider is no longer practicing at the single location listed below.
Individual Provider Name:
Specialty:
IL License Number:
Individual's Type 1 NPI:
(Must be 10 digits)
Address 1:
(Where the provider saw patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:
Effective Date of Termination:

The following individual provider is no longer affiliated with any of our practice locations.
Individual Provider Name:
Specialty:
IL License Number:
Individual's Type 1 NPI:
(Must be 10 digits)
Address 1:
(Where the provider saw patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:
Effective Date of Termination:

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