BCBSNM Agreement - Network Participation Request FormNetwork Participation Agreement • August 11th, 2010
Contract Type FiledAugust 11th, 2010Note: Before you complete the BCBSNM Agreement Network Participation Online Request Form below, you must have obtained a BCBSNM Provider Record ID. * Indicates a required field, if applicable The agreement is written for all lines of business. Please indicate in Exhibit II of the agreement if you must exclude a line of business. This includes HMO, PPO, PAR, POS, and FEP. Are you applying as a: Yes No - Primary Care PhysicianYes No - Specialty Care Physician/other Professional Provider Yes No - Primary Care/Specialty Care Physician/otherProfessional Provider *Practicing Specialty: *Please select the category or categories that best describe(s)your practice:See page 2 for categorydescriptions Solo PhysicianSolo Health Care Professional Medical GroupHealth Care Professional Group Hospital or Facility Based Provider(s) *Provider Name: *TAX ID #: *Type 1 NPI Number Group Name: Type 2 NPI Number Is provider indicated above being added to an existing Group Contract/Agreement?