To submit a new enrollment or make changes to your existing information, select your classification type below.


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Which action do you need to perform?


In addition to listing documents needed to complete your request, the Required Document Checklist contains a list of items you should have available in order to complete the needed forms. Please review the checklist before you begin.


Enroll a new provider

Change an existing provider

Terminate an existing provider
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What type of facility are you?

Facilities
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What type of provider are you?

Practitioners
Behavioral Health
Mid-level (health care) Practitioners
Dental
Professional Group Practice
Vision
Hearing
Allied Providers
Allied Health Practitioners
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Select one or more classifications below representing practitioner members of the Group:

Practitioners
Mid-level (health care) Practitioners
Allied Health Practitioners
Behavioral Health
Hearing
Vision
Dental
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Is the practitioner an incorporated individual? prac
Do you wish to add the new practitioner to an existing Professional Group?
Is the practitioner applying to provide behavioral health
services? behavioral

Doespractitioner provide behavioral health
services? MHP

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Save time on future group updates by registering for the new Provider Enrollment and Change Self-Service application.

Practitioner forms and documents

  • Sign and return
  • Save for your records
  • Completed

BCN agreements and signature documents
BCN will send contracts under separate cover as applicable upon receipt and review of your application materials.

Doing business electronically saves your office time and money. See what services we offer to streamline your business processes and make doing business with us easier:

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BCBSM agreements and signature documents
BCBSM will send contracts under separate cover as applicable upon receipt and review of your application materials.

BCN agreements and signature documents
BCN will send contracts under separate cover as applicable upon receipt and review of your application materials.

Doing business electronically saves your office time and money. See what services we offer to streamline your business processes and make doing business with us easier:

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