Contract Update Form: Nurse Practitioner-Primary Care Providers

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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
Section 13. New Form W-9 A new W-9 is required to verify new billing information. If you are joining a contracted group, you do not need to submit a W-9. The attached IRS Form W-9 has been completed with the name and Tax ID number to which payments will be directed. Section 14. Representations By checking this box, you hereby affirm and represent that all statements, answers, and information included in this Contract Update Form are true and complete to the best of your knowledge and belief, and that you are duly authorized to provide information on behalf of the NPPCP named in section 1. Name of person completing form: Title: Practice name: Email: Phone: ( ) Fax: ( ) Date: Section 15. Contract Recipient Where we should mail contract documents: Existing practice address in section 4 Billing address in section 4 Other: Attention of: Address: City, State, Zip code: BCBSMA Contract Update Form for NPPCP – PEP-3296E (3/13) 5 of 6
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Contract Update Form: Nurse Practitioner-Primary Care Providers

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