Contract Update Form: Nurse Practitioner-Primary Care Providers

Section 9. Covering Arrangement
This section is required if you are joining or opening a practice.
Arranging for 24-hour coverage is a credentialing and contractual requirement. Please list the physicians and/or groups that
provide coverage for you. Covering providers must be participating in the same Products that you are requesting.
Physician or Group Practice Name
NPI
Section 10. Hospital Privileges
Please complete the following chart as it relates to your hospital affiliation and admitting arrangements.
Your hospital affiliation must be a BCBSMA contracted acute care hospital and your admitting provider must be a BCBSMA
credentialed and contracted physician.
Hospital Affiliation
If you have a hospital affiliation, please provide the name of your primary acute care hospital:
__________________________________________________________________________________
If you are affiliated with secondary acute care hospital(s) and wish to have it/them listed in the directory,
please provide the name(s):
Admitting
Privileges at
Primary Acute Care
Hospital
__________________________________________________________________________________
If you have admitting privileges at the
primary acute care hospital named above,
please check this box:
If you do not have admitting privileges at your primary acute
care hospital, please indicate below who provides
arrangements for your inpatient admissions.
Check all applicable boxes:
My Collaborating Physician as indicated in section 7
The physicians affiliated with the practice in section 4
Covering physicians not affiliated with the practice in
section 4
Please note: Your covering party must complete, sign and
date section 11, Admitting Arrangement Attestation.
Section 11. Admitting Arrangement Attestation
Please have this section signed and dated by a physician who provides arrangements for your inpatient admissions.
By checking this box and signing below, the physician affirms and represents that the practice or hospitalist program name
(“covering party”) listed below provides all arrangements for inpatient admissions for the NPPPCP whose name appears
below. This arrangement will continue until such time as the NPPCP obtains admitting privileges in good standing at an
acute care hospital that is participating with BCBSMA.
Physician signature:
(signature stamp not accepted)
Physician name and title:
Date of physician signature:
Name of covering party:
Phone: ( )
NPPCP name:
Section 12. Hospital Affiliation
You (the NPPCP) are: changing your primary hospital affiliation
Name of hospital (required):
Initial date of appointment (MM/DD/YY):
adding a secondary hospital affiliation
Does your current professional staff status include admitting privileges Yes No
BCBSMA Contract Update Form for NPPCP – PEP-3296E (3/13) 4 of 6