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Anthem Blue Cross Blue Shield Health Insurance  
      Provider Maintenance Form
     

This form applies only to Connecticut facilities, physicians, providers and professionals submitting demographic and/or practice changes applicable to Anthem Blue Cross and Blue Shield in Connecticut.

Advance notice is required for name or address change, notice of retirement, or other changes relating to your practice. Please type or print clearly, and complete all required sections. When adding, changing or removing a location with multiple individual providers, a separate form is not required for each provider. Simply complete this form as applicable and then submit a list of the names/NPIs to the email mailbox, fax or mailing address shown below and it will be matched with this form. Please note that a new contract is required for any name/tax ID changes or for a new provider - contact Provider Relations for the contract forms you will need to complete in addition to this Provider Maintenance Form (PMF). Until we have approved the appropriate contracts and have sent notification of acceptance as a network provider, new providers will not be considered participating providers and should not see Anthem members. In addition, please be certain to use the following instructions when making any change(s) requiring a new IRS Form W9, as the Form W9 must be submitted SEPARATELY from the PMF:

  1. Complete all applicable sections of the PMF.
  2. Before clicking the 'Submit' button at the bottom of the PMF, note if the change(s) require a new Form W9.
  3. If so, complete a new IRS Form W9 and submit it to the following email address ProviderDemographics@anthem.com, or if you prefer, you can fax or mail it to the fax number and address listed at the bottom of this PMF.

Please provide 60 days notice of termination from our network.

Please click each of the section headings to complete the form.

 
SECTION A: GENERAL INFORMATION **REQUIRED**

 Required field.

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

 

 Provider's Name: 
 Primary Care Provider 
 Specialist - note specialty:
 Group Practice Name: 
 Group/Practice Tax ID (EIN/SSN): 
 Anthem Provider ID if known: 
National Provider Identifier (NPI)
 Entity 1: 
 Entity 2 (if applicable): 
Taxonomy Code
 Entity 1: 
 Entity 2 (if applicable): 
SECTION B: REASON FOR SUBMITTING FORM **REQUIRED**

 Required field.

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

 

 Reason for Submitting Form: Add  Change  Cancellation  
 Effective date of add/change/cancellation: // (cannot be retroactive) 
 Provider name change - new contract, W-9 and copy of license required (complete section C)
 Adding provider (complete section C) W-9, contract, and copy of license required
 Adding or deleting covering physician (complete section G)
 Practice name change - W9, new contract required (complete secton E)
 Deleting provider (complete section C)
 Acceptance-of-member status change PCP only(complete section C)
 Practice address or billing address change (complete sections D and E)
 Adding location (complete section F)
 Deleting location (complete section F)
 Tax ID number change - W9, new contract required
      Old Tax ID    New Tax ID
 Other (please explain)
      
 Briefly describe the reason for submitting this form:
      
SECTION C: PROVIDER INFORMATION

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

Provider Name First, MI
    MI
 
Last Name (for name change, include previous and new names)
Prev:      New: 
 
SSN:
Specialty:
License:
 
M   F
 
Date of Birth:
 
Acceptance of New Members (PCPs only):
Open   Closed   Family of current patients only
SECTION D: CURRENT ADDRESS Note - if current address is to be deleted, complete this section with the current address information.

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

Practice Information
 
Address
City
State
Zip
Phone
Fax
Email
 
Billing Information
 
Address
City
State
Zip
Phone
Fax
Email
SECTION E: NEW PRACTICE NAME and/or NEW ADDRESS Note - if changing practice name or address, include new information here.

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

Practice Information
 
Name
Address
City
State
Zip
Phone
Fax
Email
 
Billing Information
 
Address
City
State
Zip
Phone
Fax
Email
 
Correspondence Address (if applicable, note "same as...")
 
City
State
Zip
SECTION F: ADDITIONAL OFFICE LOCATION(S)

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

Add Delete
Practice Information
 
Additional Name (if different from practice name in Section A)
New Tax ID number (if applicable)
New NPI - Entity 2 (If applicable)
Email
Phone
Fax
Address
City
State
Zip
 
Billing Information
 
Address
City
State
Zip
Phone
Fax
Email
 
Correspondence Address (if applicable, note "same as...")
 
City
State
Zip
 
Add Delete
Practice Information
 
Additional Name (if different from practice name in Section A)
New Tax ID number (if applicable)
New NPI - Entity 2 (If applicable)
Email
Phone
Fax
Address
City
State
Zip
 
Billing Information
 
Address
City
State
Zip
Phone
Fax
Email
Correspondence Address (if applicable, note "same as...")
City
State
Zip
SECTION G: COVERING PHYSICIANS

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

Add or Delete?  Provider Name/Degree Specialty NPI# Effective Date
SECTION H: CONTACT SIGNATURE **REQUIRED**

 Required field.

Please be sure to complete and submit an IRS Form W9 if required for the requested change.

 

 Provider Office Contact Name: 
 Phone : 
 Date: 

 

By clicking on the tab marked "SUBMIT" below, I hereby request the above changes and certify that the foregoing information is true and correct and that I am the named professional or am otherwise authorized to make this request and certification on behalf of the named professional.

Please note: To avoid processing delays, please review this form before submitting to ensure that all required areas have been completed.

Click on the Submit button below or, if submitting manually, please fax to your Provider Relations Representative, or mail to: Anthem Blue Cross and Blue Shield, Provider Relations; Mail Code CT0304-0075; 108 Leigus Road, Wallingford, CT 06492

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