BCBSNC PROV ID # TAX ID out of state only 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Prescriber Name and NPI, ensuring that the NPI is marked as required.
3. Fill in the Contact Person's name and their phone number for any follow-up communication.
4. In the BCBSNC PROV ID # / TAX ID section, input your 5-digit provider ID if you are an out-of-state provider.
5. Complete the Prescriber Address fields including City, State, and ZIP code accurately.
6. Enter Patient Name and BCBSNC ID, followed by the Patient's Date of Birth and Gender.
7. Indicate whether Revlimid is a formulary drug by checking 'Yes' or 'No'.
8. Provide the Dx Code and select the appropriate condition for which Revlimid is prescribed by checking one of the boxes.
9. Finally, certify your request by signing and dating at the bottom of the form before submission.

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