Blue Cross Blue Shield of Illinois - Request Removal of Provider from Group

What's New

Request Removal of Provider from Group

Reminders:

You may specify more than one change within your request when all changes relate to the same billing (Type 2) NPI. Changes involving multiple billing NPIs and/or multiple providers within a group must be requested on a spreadsheet, rather than via this online form.
Changes are not immediate upon submission of this form. Processing can take a minimum of 45 business days.

* Required Field

Step 1: Your Current Group Information: [Group’s identification information already on file with BCBSIL]*
Group Name:
Group Tax ID: (must be 9 digits)
Group Type 2 NPI: (Must be 10 digits)
Contact Name and Title:
Contact Telephone Number:
*Step 2: Departing Provider Information
The following individual provider is no longer practicing at the single location listed below.
Individual Provider Name:
Specialty:
IL License Number:
Individual's Type 1 NPI: (Must be 10 digits)
Address 1: (Where the provider saw patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:
Effective Date of Termination:
The following individual provider is no longer affiliated with any of our practice locations.
Individual Provider Name:
Specialty:
IL License Number:
Individual's Type 1 NPI: (Must be 10 digits)
Address 1: (Where the provider saw patients)
Address 2:
City:
State:
Zip:
Telephone Number:
Fax Number:
E-mail:
Effective Date of Termination:
*Step 3: Attestation
Attestation: I hereby certify that the information submitted within this form is accurate and complete.