Provider Secured ServicesID Reassignment Form

FAX COVER PAGE

Fax To:

From (office):

Date:

SEP19

• We cannot accept handwritten forms.• Do not hand write anywhere on the forms(except for the signature), otherwise

processing will be delayed.• To ensure forms are processed timely, please adhere to the following instructions :

o Enter all information online(Google Chrome or Internet Explorer work best).o Press the tab key after each entry to move from field to field.

We’re always looking for ways to protect our member’s information and keep your account secure. That’s why we’d like to connect your online account to an email address that’s related to your business rather than a public email provider such as Hotmail, Gmail or Yahoo.

If you have a company email address, please include it on your request for access or changes to your Provider Secured Services account at bcbsm.com. If you’re not sure whether a company email address is available to you, check with your website administrator. Most websites offer a domain email free with your account. If you’re a smaller practice that doesn’t host a website, we’ll accept your request with the email you use to conduct your business.

PLEASE NOTE!!

**ATTENTION**

Contact:

Provider Secured Services ID Reassignment

Practice or Facility Name: Contact Person:

Street Address and Suite Number: Contact Person's Telephone and Extension:

City: State: ZIP Code: Contact Person's Company Issued Email Address:

This form allows you to reassign an existing Provider Secured Services ID that is no longer being used by your practice to another user in your practice. List below each Provider Secured Services ID you would like to reassign, the previous user, the new user, and the new user's telephone number.

The access assigned to the current Provider Secured Services ID will be transferred to the new user. This includes, but is not limited to: Eligibility, Claims Tracking, Electronic Funds Transfer (EFT), Internet Claims Transmission (ICT), and Provider Enrollment Change Self-Service. The new user will be bound to the original terms and conditions of all access that has been acquired. Note: Reassigned users with access to Provider Enrollment and Change Self Service understand, acknowledge, and attest to the original terms of the Addendum G, including the authority to maintain practitioner and provider group enrollment records for all Blue Cross Blue Shield of Michigan provider codes currently associated with the user as well as any future provider codes assigned.

Provider Secured Services ID

Previous User*must match current records*

Telephone Number

Example F000000 John B Doe Jane Smith 248-222-1112 Ext. 231

If additional space is required, attach a separate listing that includes the Provider Secured Services ID, previous user, new user, and the user's telephone number.

AUTHORIZATION FOR USE AND ACCESS

Date Authorized Signature Handwritten Signature Only

Title of Authorized Individual

For Questions Call 877-258-3932 Send Fax to 800-495-0812

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Please complete electronically

Type Name of the Authorized Individual

WF 16642 MAR 21

Reassign Reconnect Disconnect

x xx

By signing below, I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority to enter into and bind my provider group to agreements. I understand, acknowledge, and attest that the user(s) listed above have the authority to perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals.In addition, I understand that by signing above I have the company’s designated authority to request and maintain minimum necessary web access and am responsible for complying with all terms and conditions contained within the Provider Secured Services Use and Protection Agreement. https://www.bcbsm.com/content/dam/public/Providers/Documents/help/faqs/use-and-protection-agreement-professional-facility.pdf

New User