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Participating Facility/Ancillary 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.

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

Provider Information

« Required

If you have additional NPI Numbers, please complete a separate form.

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« Required

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Physical Location Information

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Contact Information

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Documentation

If you are a nonparticipating provider, we require a W-9 to ensure that we have accurate IRS reporting information on file. You can fax your W-9 to (215) 238-2537, or if you have an electronic copy on file, you can use the following browse option to attach and submit the file to us.



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) 238-2537, or if you have an electronic copy on file, you can use this browse option to attach and submit the file to us.