In the section below, identify the provider codes for Blue Cross Blue Shield of Michigan, Blue Care Network, and Medicare that you wish to access claim information. Also identify all payers you wish to submit electronic claims by supplying the appropriate provider identifier. Remember BCBSM providers need to report the National Provider Identification Number (NPI).

(For BCBSM use only) Secured Access ID# COMMENTS:

If you are only requesting additional Provider Secured Services IDs, enter the User ID from this office you would like to have cloned with the same provider codes.

Contact Person's Telephone and Extension

Email Address to receive assigned Provider Secured Services ID(s)

Provider Specialty

Professional Provider Secured Access Application

Street Address and Suite Number (address where users are located) Contact Person

City State Zip Code

Are Your Claims Submitted Electronically ? Yes NoTax ID:

Provider or Group Name

Provider NPI Number

Do you formally participate with BCBSM in accepting payments? Yes No Does your office have access to Provider Secured Services? Yes No If yes, list your current Provider Secured Services ID

© 1996-2013 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

TO OBTAIN SECURED ACCESS USER IDs, YOU MUST COMPLETE PAGE 2 OF THIS FORM.

TO VIEW AN EXAMPLE OF A SPECIFIC REQUIRED CODE, PLACE THE MOUSE POINTER IN THE CENTER OF THE INPUT FIELD BELOW.

Medicare Provider Codes

WF 10905 JAN 13

Internet Claims Submission Office/Practice Name (where users are located)

( )

Mail or Fax application to: Blue Cross Blue Shield of Michigan 53200 Grand River Mail Code L830 New Hudson, MI 48165 Fax #: 1-800-495-0812

If you are cloning an ID, stop here and go to page 2 of this application.

Michigan Medicaid NPI

USERS CANNOT TAKE THEIR ASSIGNED IDs TO OTHER PRACTICES/LOCATIONS

Office/Practice Name

Provider Secured Services ID

If no, you must complete the "Use and Protection Agreement"

Select Applicable Line of Business for the assigned 10-digit NPI Number BCN BCBSM BCBSMBCN BCN BCN BCBSMBCBSM

Provider's Name

Provider's Name

Assigned 10-digit NPI Number

Assigned 10-digit NPI Number

Requesting e-Referral Access (BCN-Affiliated Providers Only)Note-All listed providers are automatically added to the existing practice/group and are immediately available for e-referral

For offices that currently have access to e-referral and are requesting access for additional users, please provide a Provider Secured Services ID for verification purposes

IF YOU HAVE ANY QUSTIONS, PLEASE CALL 877 258 3932

For BCBSM Use Only

BCN PCP Claims

Summary

Claims Tracking

& EFT

User's Telephone # and Extension

Practice Name (Provider Name)

Professional Provider Secured Access ApplicationTO OBTAIN SECURED ACCESS USER IDs, YOU MUST COMPLETE THIS FORM.

Name (Type in full legal name for each user)

EXAMPLE: John B Doe

EXAMPLE: Jane Smith

248-222-1111

AUTHORIZATION FOR USE AND ACCESSI hereby state the information provided on this application is correct and the provider codes listed pertain to my practice only.

Provider Authorized Signature Date

Type or Print Name of the Authorized Signer Signer's Title

248-222-1112 ext. 231

Internet Claims Trans

TYPE THE NAME(S) AND PHONE NUMBER(S) OF THE INDIVIDUAL(S) REQUIRING PROVIDER SECURED ACCESS CHECK ALL FEATURES YOU ARE REQUESTING FOR EACH USER

All individuals using Provider Secured Services must be included below to receive their own user ID. Provider Secured Services user IDs may not be shared among the office staff. Note: All users will automatically receive access to web-DENIS and web-DENIS eligibility.

By signing above, I represent and warrant that I have been granted full legal authority, by corporate resolution, appropriate delegated signature authority, or as permitted by a signature authorization policy, to enter into and bind the provider and/or provider group to contracts and agreements and, intending to be legally bound, have executed this agreement on the date listed above. © 1996-2013 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

NOTE: If additional space is needed, attach a separate listing of the names and telephone numbers for each user requiring secured access.

XX

X X

Do not use a signature stamp on the line above

IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-877-258-3932

e-referral Access

(BCN Only)

X

Professional Claims

Correction (PCC)

X

X