Provider Change of Address Form

PROVIDER CHANGE OF ADDRESS FORM

Mail to: Blue Cross Of Northeastern PA Or FAX to: (570) 200-6880 Provider System Support Questions: (800) 451-4447 19 N. Main St. Wilkes-Barre, PA 18711

BlueShield Provider #: ______Provider Name: ______

First Priority Health #: ______NPI #: ______

Highmark Blue Shield #: ______Tax ID #: ______

Assignment Account # ______Effective Date: ______

Please update my provider file to reflect the following:

 Add  Change Main Practice address  Add  Change Additional Practice address  Add  Change Check address  Add  Change Mailing Address

Note: If this is a new Tax ID # and/or a change in billing name, updated IRS documentation must be returned.

Main Practice Address: (primary physical practice location) Previous Main Practice Address:

______

Telephone number: ______Telephone number: ______

Fax number: ______Fax number: ______

Office Hours: ______Term Date: ______

Contact Name: ______

Note: Term date can be no earlier than one day prior to effective date at new practice

Additional Practice Addresses: (physical locations where patient receives services) Attach separate sheet for additional locations.

______

Mailing Address: (address where administrative work is done) Check/Remit Address: (address to which checks are sent)

Is this a lockbox?  Yes  No

______Signature (If Solo Practice, Doctor must sign ~ If Group, Authorized Representative can sign)

______Printed Name Date