Bluecrow42 2025

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The document is a Letter of Intent (LOI) form for providers wishing to join Anthem BlueCross and BlueShield Wisconsin's network. It outlines the necessary information required from practitioners, including personal details, practice information, and specialty specifics. The document also explains the process following submission, including potential approval notifications and credentialing requirements.

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Click ‘Get Form’ to open the bluecrow42 document in the editor.
Begin by entering your Practice Name in the designated field. This should reflect the name of your group, corporation, clinic, or agency.
Next, fill in your Practitioner Name, including your first name, middle initial, last name, and title (e.g., John A. Smith, MD).
Provide your CAQH Number and Date of Birth in the respective fields. Ensure accuracy for proper identification.
Indicate your Gender by selecting either 'F' for female or 'M' for male.
Enter your Tax Identification Number and State License Number accurately.
Specify your Specialty. If applicable, include details if you are a Behavioral Health provider.
List any languages spoken and the age range of clients you work with.
Fill in both Individual NPI Number and Group NPI Number as required.
Complete the Practice Contact Information section with your name, email, primary office address, billing office address, phone number, and fax number.
Finally, review all entries for accuracy before printing the form to fax it along with any supporting documentation to Anthem BlueCross and BlueShield New Provider Contracting at 262-523-4783.

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