<p> PROVIDER CHANGE OF ADDRESS FORM</p><p>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</p><p>BlueShield Provider #: ______Provider Name: ______</p><p>First Priority Health #: ______NPI #: ______</p><p>Highmark Blue Shield #: ______Tax ID #: ______</p><p>Assignment Account # ______Effective Date: ______</p><p>Please update my provider file to reflect the following:</p><p> Add  Change Main Practice address  Add  Change Additional Practice address  Add  Change Check address  Add  Change Mailing Address</p><p>Note: If this is a new Tax ID # and/or a change in billing name, updated IRS documentation must be returned.</p><p>Main Practice Address: (primary physical practice location) Previous Main Practice Address:</p><p>______</p><p>______</p><p>Telephone number: ______Telephone number: ______</p><p>Fax number: ______Fax number: ______</p><p>Office Hours: ______Term Date: ______</p><p>Contact Name: ______</p><p>Note: Term date can be no earlier than one day prior to effective date at new practice</p><p>Additional Practice Addresses: (physical locations where patient receives services) Attach separate sheet for additional locations.</p><p>______</p><p>______</p><p>Telephone number: ______Telephone number: ______</p><p>Fax number: ______Fax number: ______</p><p>Mailing Address: (address where administrative work is done) Check/Remit Address: (address to which checks are sent)</p><p>Telephone number: ______Telephone number: ______</p><p>Fax number: ______Fax number: ______</p><p>Is this a lockbox?  Yes  No</p><p>______Signature (If Solo Practice, Doctor must sign ~ If Group, Authorized Representative can sign)</p><p>______Printed Name Date</p>