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





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.




What type of facility are you?

Facilities

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

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

Is the practitioner an incorporated individual?


Do you wish to add the new practitioner to an existing Professional Group?


Is the practitioner applying to provide behavioral health
services?


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:

  • Provider Secured Services
  • Electronic Funds Transfer (EFT) - for BCBSM professional providers only
  • Electronic Connectivity (EDI)


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:

  • Provider Secured Services
  • Electronic Funds Transfer (EFT) - for BCBSM professional providers only
  • Electronic Connectivity (EDI)

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