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Provider setup and enrollment changes
- Demographic and Contact Information(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)(PDF)
- Terminations of Practitioners and Groups (Job aid)(PDF)
Other forms and documents
- Applied Behavioral Analysis/Adaptive Behavioral Treatment for Autism Spectrum Disorder (ABA/ABT) Fax Form(PDF)
- BetterDoctor 2022 FAQ(PDF)
- Blue e account maintenance
- Blue e interactive network agreement
- Coordination of Benefits Questionnaire(PDF)
- EFT Sign-Up(PDF)
- Electronic solutions
- Email registry sign-up
- Enrollment Pending Claims Filing Exception Form(PDF)
- E-Visit Attestation(PDF)
- E-Visit Vendor Change(PDF)
- FAQ for Electronic Credentialing and Enrollment Submission(PDF)
- FAQ for Enrollment Pending Claims Filing Process(PDF)
- Inpatient Readmission Dispute 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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