Provider Demographic Form

Instructions: Advance notice is required for name or address change, notice of retirement, or other changes relating to your practice. When adding, changing or removing a location with multiple individual providers, you may attach a list with this form. A separate form is not required for each provider. Please type and complete all required sections.

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I. Fill Out General Information

* Required Field(s)

  • Are you currently contracted with Blue KC? *
  • Yes
  • No
  • Are you currently a Medical Home Provider? *
  • Yes
  • No
  • Do you want to join the Blue KC Network?
  • Yes
  • No
  • Provider Name: *
  • Group or Provider Tax ID (EIN/SSN): *
  • Group NPI: *
  • Blue KC Provider ID: *
  • Name of Individual Completing Form: *
  • Phone: *
  • Enter a 10 digit phone number.
  • Email: *

Section A: Change Provider Name and/or Change Ownership / Tax ID

Change Provider Name

* Required Field(s)

  • Effective Date of Change: *
  • (CANNOT be Retroactive)
  • New Name: *
  • Previous Name: *

Submit proof of name change with this form (i.e., Copy of Driver, Professional or Marriage License)

Insert Attachment(s): *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Change Ownership / Tax ID

* Required Field(s)

  • Effective Date of Change: *
  • (CANNOT be Retroactive)
  • New Tax ID: *
  • Previous Tax ID: *
  • New Group NPI: *
  • Previous Group NPI: *

Submit a copy of the W-9 with this form.

Insert Attachment(s): *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Section B: New Provider Group Name and/or Update Existing Address Information

New Provider Group Name

* Required Field(s)

  • Effective Date of Change: *
  • (CANNOT be Retroactive)
  • Group Name: *

Submit a copy of the W-9 with this form.

Insert Attachment(s): *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Update Existing Address Information

* Required Field(s)

  • This change applies to: *
  • Practice Address
  • Remit/Billing Address
  • Both Practice & Remit/Billing Address
  • Effective Date of Change: *
  • (CANNOT be Retroactive)

NEW INFORMATION

  • Street: *
  • Suite:
  • City: *
  • State: *
  • Zip: *
  • Phone: *
  • Enter a 10 digit phone number.
  • Fax:
  • Enter a 10 digit phone number.

PREVIOUS INFORMATION

  • Street: *
  • Suite:
  • City: *
  • State: *
  • Zip: *
  • Phone: *
  • Enter a 10 digit phone number.
  • Fax:
  • Enter a 10 digit phone number.
  • Handicap Accessible Location? *
  • Yes
  • No

Section C: New Practitioner / Group Location

New Practitioner / Group Location

* Required Field(s)

If the change does not apply to all the practitioners in the group, please advise the names of the providers affected in the comment box below, or attach the correct documentation.

ADD TERM Practice Address * Suite /
BLDG #
CITY * STATE* ZIP * PHONE * FAX Effective Date of Change * Apply this Change to ALL Practitioners?*
Yes
No
Yes
No
Yes
No

Insert Attachment(s):

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Section D: Add, Change or Remove Practitioner and/or Location

Provider Information

* Required Field(s)

  • Add
  • Update *
  • Provider Name: *
  • Individual NPI #: *
  • Primary Care Physician
  • Specialist
  • List Specialty:
  • Accepting New Patients? *
  • Yes
  • No
  • Mid-Level
  • Collaborative Provider Name:
  • Collaborative Provider NPI #:
  • Other (Describe)

Licensed in:

  • MO:
  • KS:
  • Accepts Medicare? *
  • Yes
  • No
  • Accepts Medicaid? *
  • Yes
  • No
  • Effective Date of Change: *
  • (CANNOT be Retroactive)
  • Assign practitioner to ALL practice locations (new to practice)
  • Assign to the following practice locations ONLY:
ADD TERM Practice Address * Suite /
BLDG #
CITY * STATE* ZIP * PHONE * FAX Effective Date of Change *

Remove Practitioner and/or Location

* Required Field(s)

  • Effective Date of Change: *
  • (CANNOT be Retroactive)

Please enter the following information below:

  1. Practitioner Name and/or Location to be Removed
  2. Individual NPI #
  3. Primary Care OR Specialist - if Specialist, list Specialty

If PCP, move members/patients to the following physician:

  • Remove Practitioner from ALL practice locations

Enter Reason for Leaving: *

  • Remove from the following practice locations only
Group ID # * Practice Address *

  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to one of the following:

Local HMO/PPO 816-395-3959.

Blue Card 816-395-3860

FEP 816-395-3811

Or mail to:

For local business:
Blue Cross Blue Shield of Kansas City
Attn: Correspondence
PO Box 419169
Kansas City, MO 64141-6169

For Blue Card:
Blue Cross Blue Shield of Kansas City
Attn: Correspondence
PO Box 419016
Kansas City, MO 64141-6016

For FEP:
Blue Cross Blue Shield of Kansas City
Attn: Correspondence
PO Box 419071
Kansas City, MO 64179-0288

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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