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Nonparticipating Nonmedical/Atypical 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 nonmedical/atypical providers (e.g., nonmedical transportation).

*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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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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Documentation

We require a W-9 to ensure that we have accurate IRS reporting information on file. You can fax your W-9 to (215) 238-2537, or if you have an electronic copy on file, you can use the following browse option to attach and submit the file to us. We must receive your W-9 within 24 hours of your submission. If you do not provide your W-9 within 24 hours, we will deny your registration and you will have to resubmit.