Loading
Form preview picture

Get Bmc Pdffilter

Primary Practice Address Line 1 City State Office Phone Office Fax Billing Information Billing Name Address Billing Contact TAX ID Comments Add Below Zip code Office Contact Phone Fax Please Attach Copy of W-9 Form Non-contracted providers treating members of BMC HealthNet Plan must obtain pre-authorization prior to delivering services to Plan members. BOSTON MEDICAL CENTER HEALTH NET PLAN NON-PARTICIPATING PROVIDER ACTIVATION FORM You must fax this completed form and a copy of your W-9 to 617-897-0818. If you do not this will cause a delay in the processing of your claims. Date of Request Referral/Auth. Requested By Department Member Name BMCHP Member Member Plan PROVIDER INFORMATION Please complete all applicable fields below. If the provider information is not complete it will delay the processing of this request. Practitioner Entity Facility Group Provider Name Provider NPI Provider Title i*e* MD DMO PA Group Name if applicable Provider s SSN License Provider s DOB E- Mail Address Specialty Gender Your e-mail address is required to receive notification you that you may submit claims. BMC HealthNet Plan pre-authorization forms can be found on the Provider Page of our website at www. bmchp*org. You may also contact the pre-authorization team by phone at 1-800-900-1451 Option 3. Failure to obtain prior authorization may result in a denial of your claim* 8/27/2010. BOSTON MEDICAL CENTER HEALTH NET PLAN NON-PARTICIPATING PROVIDER ACTIVATION FORM You must fax this completed form and a copy of your W-9 to 617-897-0818. If you do not this will cause a delay in the processing of your claims. Date of Request Referral/Auth. If you do not this will cause a delay in the processing of your claims. Date of Request Referral/Auth. Requested By Department Member Name BMCHP Member Member Plan PROVIDER INFORMATION Please complete all applicable fields below. Requested By Department Member Name BMCHP Member Member Plan PROVIDER INFORMATION Please complete all applicable fields below. If the provider information is not complete it will delay the processing of this request. Practitioner Entity Facility Group Provider Name Provider NPI Provider Title i*e* MD DMO PA Group Name if applicable Provider s SSN License Provider s DOB E- Mail Address Specialty Gender Your e-mail address is required to receive notification you that you may submit claims. BMC HealthNet Plan pre-authorization forms can be found on the Provider Page of our website at www. bmchp*org. You may also contact the pre-authorization team by phone at 1-800-900-1451 Option 3. Failure to obtain prior authorization may result in a denial of your claim* 8/27/2010. BOSTON MEDICAL CENTER HEALTH NET PLAN NON-PARTICIPATING PROVIDER ACTIVATION FORM You must fax this completed form and a copy of your W-9 to 617-897-0818. If you do not this will cause a delay in the processing of your claims. Date of Request Referral/Auth. Requested By Department Member Name BMCHP Member Member Plan PROVIDER INFORMATION Please complete all applicable fields below.

How It Works

AUTH rating
4.8Satisfied
48 votes

Tips on how to fill out, edit and sign Notification online

How to fill out and sign Practitioner online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Experience all the key benefits of completing and submitting legal forms online. Using our platform filling in Bmc Pdffilter requires just a couple of minutes. We make that possible by offering you access to our full-fledged editor effective at altering/correcting a document?s initial textual content, adding special boxes, and putting your signature on.

Fill out Bmc Pdffilter in several clicks by following the instructions listed below:

  1. Choose the template you need from our collection of legal form samples.
  2. Click on the Get form key to open the document and begin editing.
  3. Fill in all of the requested boxes (these are yellow-colored).
  4. The Signature Wizard will allow you to insert your e-autograph as soon as you?ve finished imputing info.
  5. Insert the date.
  6. Look through the whole document to make sure you have completed all the information and no changes are needed.
  7. Click Done and download the filled out template to the device.

Send your new Bmc Pdffilter in a digital form when you are done with completing it. Your data is securely protected, because we keep to the most up-to-date security standards. Join millions of happy clients who are already submitting legal templates straight from their houses.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Pre FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Bmc Pdffilter

  • DMO
  • SSN
  • AUTH
  • dob
  • applicable
  • Providers
  • pre
  • referral
  • notification
  • MD
  • Activation
  • Practitioner
  • org
  • participating
  • provider
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.