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Solo provider record id information form packet 2013-2026
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- Click ‘Get Form’ to open the solo provider record id information form packet 2013 in the editor.
- Begin with Section A: Provider of Service Information. Fill in your practice address, phone number, and specialty. Ensure that you only indicate one specialty that represents the majority of your practice.
- Proceed to Section B: Billing Information. Enter your Tax Identification Number (TIN) or Employer Identification Number (EIN). Confirm whether it is a personal taxpayer number or belongs to a corporation by selecting 'Yes' or 'No'.
- Complete the contact name and accounting address fields accurately. Attach a copy of your entity’s W-9 as required.
- If applicable, fill out the Group Member Information Form for each practitioner in your group, ensuring all details are accurate and complete.
- Review all sections for completeness before submitting the form via fax or mail to Blue Cross and Blue Shield of Texas as indicated.
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