NPI Dissemination Form for BCBSM 2026

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Click ‘Get Form’ to open the NPI Dissemination Form in our platform's editor.
Begin by filling out the NPI Number field. This is crucial as it identifies your Medicare NPIs registered with Medicare.
Next, enter the Medicare Legacy Number associated with each NPI. This number helps link your NPI to your Medicare records.
In the BCBSM Provider PIN section, input the PIN that should be linked to your NPI. This ensures proper processing of claims.
Fill in the Tax ID number related to your practice. This is necessary for accurate identification and billing purposes.
Finally, sign as an Authorized Representative and provide a contact telephone number for any follow-up inquiries.
Once completed, save your form and utilize our platform’s features to fax it directly to the Provider Enrollment NPI Unit at 866-504-0449.

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