2009 045 Ordinance - Laserfiche WebLink

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ANTHEM Bi,iTE CROSS AND BLIJE SHIELD . PROVIDER 1VIAINTEIOTANCE FORM Anffiem. ''°o 9 . THIl2D Psactice Naffie• - Pracrice Address Remit Address (requireci) City State Zip Ciry I State Zip CountS' County Phone iNumber (parients can call) Fax Number Remit Phone Number Remit Fax Number Email Address Group NPI Medicare Crroup Number Medicare Individual Number Medicaid Group Number Medicaid Individual Number List site within Anthem's directory/ web pages? Yes ? No ? Access to Public Transportation? Yes ? No [I giandicap Accessible? yes E] No ? EVeclina Hours? Yes ? vo ? Weekend Hours? Yes ? No ? Days Office is ppen: ? M ? T? W? T? F FOURTH Practice Name: Practice Address Remit Address (required) City State Zip City State Zip County County Phone Number (patients can call) (-) - Fax Number U - Remit Phone Number U - Remit Falc Number U - Email Address Group NPI Medicare Group Number ?Medicare Individual Number Medicaid Group Number Medicaid Individual Number List site within Anthem's directory/ web pagges? Yes ? No ? Access to Public Transportation? Yes ? No ? Handicap Accessible? yes [I No ? Evening Hours? Yes ? No ? Weekend Hours? Yes ? No ? Days Office is Open: ? M ? T? W? T? F FIFTH Practice Name: Practice Address Remit Address (required) City State Zip Ciry State Zip County County Phone Number (patients can call) U - Fax Number (-> - Remit Phone Number (-_> - Remit Fax Number (-) - Email Address Group NPI Medicare Group Number Medicare Individual Number Medicaid Group Number Medicaid Individual Number List site within Anthem's directory/ web pagges? Yes ? No ? Access to Public Transportarion? Yes ? No ? Handicap Accessible? yes El No ? Evening Hours? Yes ? 1Vo ? Weekend Hours? Yes ? No ? Days Office is Open: 0 M ? T ? W? T? F Section G. COVERI??iG PHYSICMINS Nate_ FarPCf's and OS/GYNs in HMONetworks only Group Enrity Name: Speciaity: Nine (9) Digit Tax ID: Effective Date: Group Enrity Name: Specialty: Nine (9) Dia t Tax ID: Effecrive Date: Seciion H. Cf}1V`3'ACT SIGNATL'RE Provider Office Contact Phone Number Date Anthem Consultant Phone Number ? - Date I hereby verBfy that the information that is provided on this form is accurate aspresented Please nflte: To help avoid processing delays, revaev this orm bs ore submdttin . Incom lete orms ma be returned or additional in ormration. ? $/200$ Mthem Blue Cmss anM Blue SNekl is the traCe name of: ln Indiana: Mthem Insuranee Companies. Inx. In Kentucky Anthem Heatth Plans of KenNcky, Inc. In rtrost of Miaouri (exWvdirg 30 counCes in the Ka?as Ci?y area): -^' RightCHO{CEf? dAanxqed Care, Ix. (RIT}, H-Ithy Allia? life Ir?rance Company (HALIC), and HMO Missouri Im . RIT afM eertafn affiliffies adminisier trorrHMO benefifs wWenwitten by HALfC and HMO benefits urdervrtittesi by HMO (?Aiaouri, Inc. RIT and eertain affiliates oNy provide administraHve services for se{f-fuMed plans azW do not uMerv+rite beneits. In Ohia: Community Insurance Company. Irt W iscbcsin: Blue Cmss and BEue Shieid of Wis?onsin ('BCBSWi ) urtdervrtites tt atlministers the PhiPO acM indem?aN polid?; Compcare Heatth Servces tnsu2rtcepCorporaGon ('Compcz(e') undervrtites or adminisFecs the HMO polide? and Compcare aM BCBSWi w(lectivety wAermite w administer the POS policies. IndepecMenteldlicensces of fhe 81ue C. and Blue Shietd Assoaation. ?,NTFiEM is a ra3istered trademaAC of Anthem I?urance CompaMes, 1? The B(ue Cross a?M Blue Shield names aM symbols are Ne registered marks of the Blue Cross a?W Blue S AssodaCOn