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April 2013

New facility forms available on upgraded website

New, easier-to-use forms will be available on the upgraded Facility Provider Enrollment website by April 15. The forms for non-hospital facilities include:

  • Facility record update: A combined form for both BCBSM and BCN providers.
  • Network agreement and signature documents: Required for facilities wanting to participate in additional networks or new facilities doing business with BCBSM. Note: Network approvals are made after credentialing is completed.

To get the forms, visit bcbsm.com/providers and follow these steps:

  • Under Join the Blues Network, click on Enrollment.
  • Click on Provider Enrollment.
  • Follow the steps indicated to access the forms for your facility.

Return the forms to Provider Enrollment via fax at 1-866-393-8533 or mail at:

Provider Enrollment
Blue Cross Blue Shield of Michigan
P.O. Box 217
Southfield MI, 48034

Questions? Call Provider Contracting at 1-800-777-2118.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.