Provider.excellusbcbs.comcontactjoin-ourBecome a Participating ProviderProvidersExcellus ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Requested Effective Date' and 'Request type' sections. Choose from options like 'First-time application' or 'Join a new tax ID'.
3. Complete the personal information fields, including your last name, first name, middle initial, date of birth, social security number, and gender.
4. Provide your professional details such as Individual NPI #, License #, and DEA Certificate #. Ensure that you select the correct applying role from options like Nurse Practitioner or Physician Assistant.
5. Fill in your primary address with street level information. Remember to indicate if this address is handicap accessible or used for telehealth services.
6. Complete the applicant attestation section by signing and dating the form. Ensure all required documents are attached before submission.

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