Please complete this form with as much information as possible. The receipt of accurate, up-to-date information is vital to ensuring successful registration with Independence Blue Cross.
Note: If you are a nonparticipating provider with Independence Blue Cross, please use the proper registration form (based on your provider type). This form is for nonpar facility/ancillary providers (e.g., Hospitals, Rehabs, DMEs, Ambulance, etc.).
*Denotes a required field. Please review the required fields before filling out the form.