Blue shield icf form 2026

The Individual Practitioner Information Change Form (ICF-01) is used by Blue Shield of California and Blue Shield Promise to update existing practitioner records. It requires the identification of the practitioner and completion of relevant fields for changes, along with necessary documentation. The form must be submitted via email, and it is important to note that this form does not create a new practitioner record or serve as an agreement to join the provider network.

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Click ‘Get Form’ to open the blue shield ICF form in the editor.
Begin by identifying the practitioner requiring changes. Fill in the Practitioner Name, Tax Identification Number (TIN), and National Provider Identifier (NPI) fields accurately.
For any changes, check the appropriate box (ADD, CHANGE, REMOVE) and complete the corresponding columns for existing and new information as needed.
Attach all required documentation based on your changes. For example, if changing your TIN, include a signed W-9 form.
Review all entries for accuracy before submitting. Ensure that all applicable fields are filled out completely.
Once completed, return this form via email to Blue Shield at BSCProviderInfo@blueshieldca.com.

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