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ANCILLARY PROVIDER ID REQUEST FORM Blue Cross and 2026

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The document is an Ancillary Provider ID Request Form for Blue Cross and Blue Shield of Texas (BCBSTX), intended for establishing an Out-of-Network provider ID. It requires detailed information about the service provider, including corporate name, address, contact details, and tax identification information. The form also includes sections to indicate the provider's status in relation to a main hospital and requires signatures for verification. Additional documentation such as a facility license, W-9 form, and NPI confirmation must be attached.

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How to use or fill out ANCILLARY PROVIDER ID REQUEST FORM Blue Cross and Blue Shield of Texas

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form. This is essential for processing your request.
Fill in the 'Provider of Service Information' section with your corporate name, address, and contact details. Ensure accuracy as this information is crucial for identification.
Complete the 'Tax I.D Information' section with your Federal Tax ID number and payee address. If applicable, indicate if you are adding an affiliate location to a parent hospital.
Sign and date the form at the bottom, confirming that all provided information is accurate. Attach required documents such as your facility license, signed W-9 form, and NPI confirmation.

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Versions	Form popularity	Fillable & printable
2023	4.2 Satisfied (49 Votes)
2022	4.8 Satisfied (55 Votes)
2020	4.8 Satisfied (247 Votes)
2020	4.2 Satisfied (36 Votes)
2020	4.8 Satisfied (101 Votes)
2020	4.4 Satisfied (134 Votes)
2020	4.3 Satisfied (26 Votes)
2020	4.7 Satisfied (51 Votes)
2020	4.8 Satisfied (261 Votes)
2020	4.1 Satisfied (59 Votes)
2020	4.8 Satisfied (117 Votes)
2019	4.8 Satisfied (35 Votes)
2019	4.8 Satisfied (142 Votes)
2019	4.8 Satisfied (54 Votes)
2019	4.8 Satisfied (51 Votes)

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ANCILLARY PROVIDER ID REQUEST FORM Blue Cross and 2026

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