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Provider Maintenance

Blue Cross and Blue Shield of Alabama enrolls and credentials all individual providers as well as ancillary and facility providers. Once a provider is enrolled and has not been inactive or canceled from participating status for six months or more, this section provides the forms/documents to add locations and make changes to information and other requests.

An application, from the Enrollment Section, is needed for any provider in the following situations:

For existing providers who are: 

Please follow the steps below:

Step 1 - Required Documents for All Providers/Specialties

There are several required documents that you must submit for enrollment. Print this handy checklist to track your progress throughout enrollment and ensure that all necessary documents/forms are submitted. Some of the required forms are provided in step 2.

Step 2 - Provider Enrollment Application/Supporting Documents

Click on the appropriate specialty from the list below to view and print the application and list of supporting documents necessary for enrollment. By utilizing the proper application and returning the correct supporting documents, you can significantly speed up the enrollment process. Submit all current supporting documentation in a legible format.

Applications/Supporting Documentation Requirements

Step 3 - Express Your Network Interest

Complete the Network Interest Form that is included with the application for your specialty. It is required for all new applications and expresses your interest in network participation. Please note: Enrollment is not the same as joining a Blue Cross Provider Network. After the enrollment process is complete, a provider will be reviewed and may be invited to participate in a network if all criteria are met.

Important - Enrollment and expressed interest in network participation are not a guarantee of acceptance as a participant in a network.

Step 4 - Enroll in Electronic Funds Transfer (EFT) - Required Effective October 1, 2012

Register Online for Direct Deposit/EFT or complete the EFT Authorization Agreement that is included with your application. EFT provides an easy and efficient way to ensure your Blue Cross and Blue Shield of Alabama payments are deposited directly into your bank account. It's secure, confidential and convenient, and there is no charge to you for this service.

Additional Documents

Application Document Package - Includes all forms that are required for new and existing providers.
 pdf Application Package

Interested in Joining a Network

  • Provider who is currently enrolled with Blue Cross and Blue Shield and is interested in participating in a network
  • Provider on initial application that indicated they were not interested in a network, but wants to reconsider

 pdf Network Interest Form

Update Office Address

 pdf Provider  Change Notification

E-mail Notification Service Form

Update Payee/Remit Address*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

Update Tax Address*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

Update Telephone Numbers

Update Provider or Office Email

Changes in Organizational/Payee NPI*
*Requires authorized, original signature of CEO, CFO, President, Tax Manager or Provider if sole owner.

 pdf NPI Change Notification

Authorization to Contact facilities for verification

 pdf Hospital Data Form

Substitute W9 Documentation

 pdf Request For Taxpayer Identification Number

Set up Direct Deposit of Remittances

 pdf EFT Authorization Form

Practitioner Rights