Provider Information Change Form - Blue Cross and Blue Shield of 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, indicate the changes needed for your provider record. Fill in the Provider/Group Name and Billing NPI Number, ensuring you use a separate form for each NPI or Tax ID change.
3. Complete Section 2 with both old and new addresses. Be thorough with street addresses, city, state, and ZIP codes. Include location phone and fax numbers as well as office hours.
4. If applicable, fill out Section 3 for any group or provider name changes without altering Tax ID or NPI numbers. Provide current and new names clearly.
5. In Section 4, add any additional addresses required for billing or correspondence. List providers practicing at these locations if necessary.
6. For termination requests, complete Section 5 with the relevant provider names, NPI numbers, termination dates, and reasons.
7. Finally, sign the form in the designated area and provide your contact information before submitting it via fax or mail as indicated.

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