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Welcome to Anthem Blue Cross and Blue Shield

Provider Maintenance Form

The Provider Maintenance Form (PMF) is to be used by California physicians, practitioners, professionals and ancillary providers to request changes to their practice profiles with Anthem BlueCross.

It is critical that our members receive accurate and current data related to provider availability. Changes to provider records that are affiliated with group contracts must be reported to and submitted by the practice manager or other designated person of authority at the group. Changes to individual contracts may be made at the direction of the contracted physician. All requests must be received by Anthem 30 days prior to the change/update. Any request received by Anthem less than 30 days prior to the change may be assigned a future effective date. Contract terms may also supersede the requested effective date. Submit the PMF to notify Anthem BlueCross of any changes to the provider/practice name, practice/mailing address, tax identification number, hospital privileges, phone and fax numbers, practice office hours, provider leaving/retiring, provider joining the practice, practice accepting new patients, handicapped accessibility, specialties or languages offered.

Please follow these instructions when submitting the PMF:

  1. Complete all applicable sections. This form has multiple options (+) for changes. Complete only the sections applicable to the requested change(s). NOTE: This form will time out after 30 minutes of activity or inactivity and all entries made but not yet submitted will be lost.
  2. Before clicking on the 'Submit' button at the bottom of the PMF, indicate if the change(s) require a valid W-9 (such as ALL Tax ID changes), as the W-9 must be submitted SEPARATELY from the PMF.
  3. Submit the new and/or valid W-9 form and any other additional attachments by email, fax or mail to one of the following:

Email: ProviderDatabaseAnth@wellpoint.com

Fax: (818) 234-2836

Mail:

    P.O. Box 70000
    PDM 8th Floor
    Woodland Hills, CA 91367

Reason for Submitting this Form

Option 1
  • Change your practice address or phone number
  • Add a new location to your practice
  • Close a practice location
  • Provider is leaving a group
  • Remove a provider from a location
  • Change your payment and remittance address
  • Change your office hours or days of operation
  • Name change for individual physician/practitioner
  • Change in your acceptance of new patients
  • Update or add your NPI
  • Update or add your email address
  • Add or change provider's areas of expertise (Behavioral Health providers only)
  • Add or change provider's hospital privilege(s)
  • Add or change provider's language(s) spoken
  • Add or change your provider specialty or type
CLICK HERE to make one or more of the above changes.
Option 2
  • Change your Tax Identification Number (TIN) or ownership of group practice (W-9 Required)
  • Change your practice or group name


CLICK HERE to make one or more of the above changes.

Option 3

CLICK HERE only if you need to make one or more changes in both Options 1 and 2