Solo provider record id information form packet 2013-2026

1. Click ‘Get Form’ to open the solo provider record id information form packet 2013 in the editor.
2. 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.
3. 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'.
4. Complete the contact name and accounting address fields accurately. Attach a copy of your entity’s W-9 as required.
5. If applicable, fill out the Group Member Information Form for each practitioner in your group, ensuring all details are accurate and complete.
6. 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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