Contract Update Form: Nurse Practitioner-Primary Care Providers

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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
Practice Address: City, State, Zip code: Phone: ( ) Section 6. Joining or Opening a New Practice as a Nurse Practitioner-Primary Care Provider Your NPPCP status at your current practice will end when we enroll you as an NPPCP at this new practice. In section 2, please indicate the Products you wish to participate in at this practice. If your group has a new Tax ID and Type 2 NPI, please also complete the Group Practice Attachment. Employment or start date: Practice name: DBA (as reported to the IRS): Practice Tax ID number: Practice NPI (Type 2): Practice Address: 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: ( ) Section 7. Collaborating Arrangement This section is required if you are joining or opening a practice. Please indicate your Collaborating (“supervising”) Physician(s). Each Collaborating Physician listed below must complete the Practice Guidelines Statement (see section 8). The Collaborating Physician must be participating with BCBSMA in the same Products that you indicated in section 2. Physician Name Physician Specialty NPI Section 8. Practice Guidelines Statement This section is required if you are joining or opening a practice or changing your Collaborating Physician. Please sign and date this section, then have it signed and dated by your Collaborating Physician(s). By checking this box and signing below, the physician attests that he or she has developed and signed mutually agreedupon, written practice guidelines for the NPPCP whose name appears below. Collaborating Physician signature: (signature stamp not accepted) Collaborating Physician name: Date of physician signature: NPPCP signature: (signature stamp not accepted) NPPCP name: Date of NPPCP signature: BCBSMA Contract Update Form for NPPCP – PEP-3296E (3/13) 3 of 6
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Contract Update Form: Nurse Practitioner-Primary Care Providers

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