Provider Secured Services ID Reassignment

Provider Secured Services ID Reassignment Form FAX COVER PAGE

Fax To: From (office):

Contact: Date:

PLEASE NOTE!!

? We cannot accept handwritten forms. ? Do not hand write anywhere on the forms(except for the signature), otherwise

processing will be delayed.

? To ensure forms are processed timely, please adhere to the following instructions: o Enter all information online(Google Chrome or Internet Explorer work best). o Press the tab key after each entry to move from field to field.

**ATTENTION**

We're always looking for ways to protect our member's information and keep your account secure. That's why we'd like to connect your online account to an email address that's related to your business rather than a public email provider such as Hotmail, Gmail or Yahoo. If you have a company email address, please include it on your request for access or changes to your Provider Secured Services account at . If you're not sure whether a company email address is available to you, check with your website administrator. Most websites offer a domain email free with your account. If you're a smaller practice that doesn't host a website, we'll accept your request with the email you use to conduct your business.

SEP19

Practice or Facility Name:

Provider Secured Services ID Reassignment

Please complete electronically

Contact Person:

Street Address and Suite Number: City:

State: ZIP Code:

Contact Person's Telephone and Extension: Contact Person's Company Issued Email Address:

This form allows you to reassign an existing Provider Secured Services ID that is no longer being used by your practice to another user in your practice. List below each Provider Secured Services ID you would like to reassign, the previous user, the new user, and the new user's telephone number.

The access assigned to the current Provider Secured Services ID will be transferred to the new user. This includes, but is not limited to: Eligibility, Claims

Tracking, Electronic Funds Transfer (EFT), Internet Claims Transmission (ICT), and Provider Enrollment Change Self-Service. The new user will be bound to

the original terms and conditions of all access that has been acquired.

Note: Reassigned users with access to Provider Enrollment and Change Self Service understand, acknowledge, and attest to the original terms of the

Addendum G, including the authority to maintain practitioner and provider group enrollment records for all Blue Cross Blue Shield of Michigan provider

codes currently associated with the user as well as any future provider codes assigned.

Provider Secured Services ID

Example F000000

Previous User

*must match current records*

John B Doe

New User Jane Smith

Telephone Number Reassign Reconnect Disconnect

248-222-1112 Ext. 231

x

x

x

If additional space is required, attach a separate listing that includes the Provider Secured Services ID, previous user, new user, and the user's telephone number.

By signing below, I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority to enter into and bind my provider group to agreements. I understand, acknowledge, and attest that the user(s) listed above have the authority to perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals. In addition, I understand that by signing above I have the company's designated authority to request and maintain minimum necessary web access and am responsible for complying with all terms and conditions contained within the Provider Secured Services Use and Protection Agreement.

AUTHORIZATION FOR USE AND ACCESS

Authorized Signature Handwritten Signature Only

Date

Type Name of the Authorized Individual

Title of Authorized Individual

For Questions Call 877-258-3932

Send Fax to 800-495-0812

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

WF 16642 MAR 21

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