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Nonparticipating Facility/Ancillary Provider Registration Form

Please complete this form with as much information as possible. The receipt of accurate, up-to-date information is vital to ensuring successful registration with Independence Blue Cross.

Note: If you are a nonparticipating provider with Independence Blue Cross, please use the proper registration form (based on your provider type). This form is for nonpar facility/ancillary providers (e.g., Hospitals, Rehabs, DMEs, Ambulance, etc.).

*Denotes a required field. Please review the required fields before filling out the form.

Provider Information

If you have previously submitted a claim to Independence Blue Cross, please enter your Provider number.


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If you have additional NPI numbers, please complete a separate form for each NPI.


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Pay To Information

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Physical Location Information

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Mailing Address (If different than Pay To or Physical Location Information)










Other Physical Location Information










Contact Information

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