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Provider setup and enrollment changes
- Demographic Change Form (PDF)
- Demographic and Contact Information (Job aid) (PDF)
- Individual Practitioner Enrollment Application
- Provider Group Enrollment Application
- Organizational Ownership (Job aid) (PDF)
- Provider Acquisition Form
- Taxpayer ID Form W9 (PDF)
- Taxpayer ID Form W9 (Job aid) (PDF)
- Tax Identification and Legal Names (Job aid)
- Terminations of Practitioners and Groups (Job aid)
Other forms and documents
- Annual Provider Update (PDF)
- Applied Behavioral Analysis / Adaptive Behavioral Treatment for Autism Spectrum Disorder (ABA/ABT) Fax Form (PDF)
-
BetterDoctor FAQ - Blue e Account Maintenance
- Blue e Interactive Network Agreement
- Commercial Intensive Outpatient Program (IOP) Authorization Request Form (PDF)
- Commercial Partial Hospitalization Programs (PHP) Authorization Request Form (PDF)
- Coordination of Benefits Questionnaire (PDF)
- Electronic Solutions
- Email Registry Sign-Up
- Facility Emergency Department Level Dispute Form (PDF)
- FAQ for Electronic Credentialing and Enrollment Submission (PDF)
- FAQ for Enrollment Pending Claims Filing Process (PDF)
- Inpatient Readmission Dispute Form (PDF)
- Itemized Bill Reconsideration Form (PDF)
- Level I Appeals (PDF)
- Medicare BH Psych Testing Form (PDF)
- Medicare Level I Appeals (PDF)
- Member Appeal Representation Authorization Form
- Post Service - Ambulance Trip Sheet Form (PDF)
- Post Service - Dermatology Patch Allergy Testing Form (PDF)
- Post Service - Hemodialysis Treatment for ESRD Form (PDF)
- Post Service - Medical Records Fax Sign-Up Form (PDF)
- Post Service - Intraoperative Neurophysiologic Monitoring Form (PDF)
- Post Service - Nerve Fiber Form (PDF)
- Provider / Doctor Claim Inquiry (PDF)
- Provider Evaluation Form (PDF)
- Provider Refund Return Form (PDF)
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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