Get Individual Pca Form

Blue Cross and Blue Shield of Minnesota Individual PCA Data Sheet Fax to 651 662-6684 or Mail to BCBSMN PDO R316 P. 07 Subdivision 4. To add more individual PCA service providers please complete and submit a new Individual Data sheet. O. Box 64560 St* Paul MN 55164-0560 Please complete this form when adding or terminating an invididual PCA service provider in a supervisory or nonsupervisory role. If you have any questions contact Provider Service at 651 662-5200 or 1-800-262-0820. Agency Information Date of Request PCA Agency Name BCBSMN ID Street PCA Agency NPI/UMPI City PCA Information St Add to this location Effective Date Last Name Social Security PCA Agency Tax ID Zip Term from this location First Name NPI/UMPI Mid Init Gender Date of Birth Title Supervisory position Person Completing Form E-Mail Address Signature Phone Submit by Email Fax Print The Sender of this Form represents and warrants that he/she is authorized to submit these changes on behalf of the Provider. By submitting this Form the Sender attests that he/she has verified the qualifications of any Qualified Developmental Disabilities Specialists noted on this form per MN State Statute 245B. O. Box 64560 St* Paul MN 55164-0560 Please complete this form when adding or terminating an invididual PCA service provider in a supervisory or nonsupervisory role. If you have any questions contact Provider Service at 651 662-5200 or 1-800-262-0820. Agency Information Date of Request PCA Agency Name BCBSMN ID Street PCA Agency NPI/UMPI City PCA Information St Add to this location Effective Date Last Name Social Security PCA Agency Tax ID Zip Term from this location First Name NPI/UMPI Mid Init Gender Date of Birth Title Supervisory position Person Completing Form E-Mail Address Signature Phone Submit by Email Fax Print The Sender of this Form represents and warrants that he/she is authorized to submit these changes on behalf of the Provider. If you have any questions contact Provider Service at 651 662-5200 or 1-800-262-0820. Agency Information Date of Request PCA Agency Name BCBSMN ID Street PCA Agency NPI/UMPI City PCA Information St Add to this location Effective Date Last Name Social Security PCA Agency Tax ID Zip Term from this location First Name NPI/UMPI Mid Init Gender Date of Birth Title Supervisory position Person Completing Form E-Mail Address Signature Phone Submit by Email Fax Print The Sender of this Form represents and warrants that he/she is authorized to submit these changes on behalf of the Provider. By submitting this Form the Sender attests that he/she has verified the qualifications of any Qualified Developmental Disabilities Specialists noted on this form per MN State Statute 245B. O. Box 64560 St* Paul MN 55164-0560 Please complete this form when adding or terminating an invididual PCA service provider in a supervisory or nonsupervisory role. If you have any questions contact Provider Service at 651 662-5200 or 1-800-262-0820. Agency Information Date of Request PCA Agency Name BCBSMN ID Street PCA Agency NPI/UMPI City PCA Information St Add to this location Effective Date Last Name Social Security PCA Agency Tax ID Zip Term from this location First Name NPI/UMPI Mid Init Gender Date of Birth Title Supervisory position Person Completing Form E-Mail Address Signature Phone Submit by Email Fax Print The Sender of this Form represents and warrants that he/she is authorized to submit these changes on behalf of the Provider. By submitting this Form the Sender attests that he/she has verified the qualifications of any Qualified Developmental Disabilities Specialists noted on this form per MN State Statute 245B. .