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Nonparticipating Professional Provider Registration Form

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 professional providers (e.g., PCPs and Specialists).

*Denotes a required field. Please review the required fields before filling out the form.

Provider Information

If you have previously submitted a claim to Independence Blue Cross, please enter your Provider number.


« Required

If you have additional NPI numbers, please complete a separate form for each NPI.

Type 1 (individual)
Type 2 (organization) « Required
« Required

« Required

« Required

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Billing Information

« Required

« Required
« Required
« Required




Physical Location Information

« Required

« Required
« Required
« Required
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Mailing Address (If different than Billing or Physical Location Information)










Contact Information

« Required
« Required


« Required
« Required


Documentation

We require a W-9 to ensure that we have accurate IRS reporting information on file. You can fax your W-9 to (215) 238-2535, or if you have an electronic copy on file, you can use the following browse option to attach and submit the file to us. We must receive your W-9 within 24 hours of your submission. If you do not provide your W-9 within 24 hours, we will deny your registration and you will have to resubmit.



Please provide a copy of the NPI Enumerator confirmation letter issued by the National Plan and Provider Enumerator System (NPPES). NPPES is the agency that assigns NPI numbers. We will use your NPI Enumerator confirmation letter for verification purposes. You can fax your NPI Enumerator confirmation letter to (215) 238-2535, or if you have an electronic copy on file, you can use this browse option to attach and submit the file to us.