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Nonparticipating Professional 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 professional providers (e.g., PCPs and Specialists).

*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.


« Required

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

Type 1 (individual)
Type 2 (organization) « Required
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Billing Information

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« Required
« Required
« Required




Physical Location Information

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« Required
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Mailing Address (If different than Billing or Physical Location Information)










Contact Information

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« Required


« Required
« Required