Managed Care Behavioral Health Network Screening Form

Copyright © 2008 by
Blue Cross Blue Shield of Massachusetts
Managed Care Behavioral Health Network
Screening Form
Please fax this completed form to 617-246-5053.
..............................................................................
Please complete this form so that we have all the information necessary to consider your request for participation
in the Managed Care Behavioral Health Network. Please note that this form is not an application for network
participation.
Please note: If you are requesting participation as a group, you must complete a form for each provider
in the group. Upon completion, attach with a cover letter detailing the number of providers participating in the
group by specialty. If you are not inquiring about group participation, please ignore the “Group Information” box
below.
Group Information (only applicable if requesting network access as a Group)
Group name:
Tax identification number:
Group's national provider identifier:
BCBSMA provider number, if any:
Address/Town/Zip:
Provider Information
Your name:
Massachusetts license number:
Tax identification number:
National provider identifier:
Address/Town/Zip:
Telephone number: ( )
Fax number: ( )
Please indicate your certification: Psychiatrist RNCS with prescribing privileges
LICSW
LMHC
LMFT
Clinical Psychologist
RNCS without prescribing privileges
Child Psychiatrist
Please contact us at 1-800-316-2583, Option 3, if your specialty is not shown above.
Please check if you have proven
clinical expertise in either:
Child/Adolescent Treatment
Eating Disorders
Attach applicable certifications or appropriate degree of training, etc.
BCBSMA comprises Blue Cross Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue ® , Inc. ®
Registered Mark of the Blue Cross Blue Shield Association.
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BCBSMA Managed Care Behavioral Health Network Screening Form 1 of 2

Copyright © 2008 by
Blue Cross Blue Shield of Massachusetts
Managed Care Behavioral Health Network
Screening Form
Please fax this completed form to 617-246-5053.
..............................................................................
Provider Information
Your name:
Massachusetts license number:
Service Information
Do you accept admissions or offer appointments: after hours Yes No
evenings Yes No
weekends Yes No
Please list languages other than English
(including sign language) that you speak fluently
and in which you can conduct treatment:
Description of Services
Please describe the geographic area in which you currently provide services, and the hospitals/physician groups
that refer to you:
Please describe any unique specialty or services that you or your organization currently provide(s). Please be as
specific as possible:
Please explain why you would like your organization to become a BCBSMA provider:
PEP-2497B (rev. 2/08)
BCBSMA Managed Care Behavioral Health Network Screening Form 2 of 2