Identifier form 2026

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The document provides detailed instructions for completing and submitting a fax cover sheet for new practitioner enrollment with Blue Cross Blue Shield of Michigan and Blue Care Network. It emphasizes the importance of entering information online without handwriting, outlines required fields for different types of providers, and specifies submission procedures to avoid processing delays. Additionally, it includes sections for demographic data, tax information, specialty, requested networks, address data, services offered, and application signature requirements.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'From' field with the name of the contact person and enter the date in MM/DD/YY format.
For individual practitioners, provide your Type 1 National Provider Identifier and State license number. If you are adding an individual to an existing group, ensure to fax a group change form.
For allied providers, complete the same fields as above but include your Type 2 NPI and Tax identification number.
If you are part of a professional group practice, repeat the process for entering your details including Type 2 NPI and Tax ID.
Ensure all required fields marked with an asterisk (*) are filled out accurately before submission.

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