Contract Update Form: Nurse Practitioner-Primary Care Providers

Your PTAN is currently pending or you have applied for but not yet received a PTAN. Date you applied:
You will not be enrolled in Medicare Advantage at this time. If you check this box when joining a group that participates in
Medicare Advantage, you must submit a new Contract Update Form for NPPCPs with your Medicare participating PTAN
within six (6) months. We'll send you new contracts to complete and return. We may terminate your participation in
the group's BCBSMA agreement unless you submit your PTAN within six (6) months.
A Medicare participating PTAN is not required because:
• neither the group practice you are joining nor your Collaborating Physician participate in Medicare Advantage, or
• you are an independently practicing provider and not applying for participation in Medicare Advantage, or
• your specialty is pediatrics only.
Section 4. Existing Practices
Each location must have a separate, designated space in which to provide care to patients, to ensure patient privacy during
treatment.
Practice name:
DBA (as reported to the IRS):
Practice Tax ID number:
Practice NPI (Type 2):
Practice Address:
Email:
City, State, Zip code:
Phone to schedule appointments: ( ) Fax: ( )
Additional locations
You provide services at additional sites that bill using the same NPI as above (please attach a list)
Billing address Same as above Other:
Billing name:
Address:
City, State, Zip code:
Email:
Phone: ( ) Fax: ( )
Additional Existing Practice
Practice name:
DBA (as reported to the IRS):
(if applicable: a practice using a separate Tax ID number and Type 2 NPI)
Practice Tax ID number:
Practice NPI (Type 2):
Practice Address:
Email:
City, State, Zip code:
Phone to schedule appointments: ( ) Fax: ( )
Additional locations
Section 5. Leaving a Practice
You provide services at additional sites that bill using the same NPI as above (please attach a list)
Please note: By leaving a practice, you will also be leaving the Product participation associated with that practice. You must
indicate in section 2 the Products in which you now wish to participate.
If leaving all BCSMA practices, submit the Enrollment Update Form for Professional Providers instead of this form.
Please check this box if you are enrolled as a Nurse Practitioner-Primary Care Provider at this practice and will be
terminating your NPPCP status to join a new practice as a Nurse Practitioner.
Date leaving practice:
Practice name:
Practice NPI (Type 2):
BCBSMA Contract Update Form for NPPCP – PEP-3296E (3/13) 2 of 6