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: This form is to request set-up in our system as a Non-Par Facility/Ancillary entity. If you are going to submit claims as Professional Provider, please fill out the Non-Par Professional form. Incorrect set-up will prevent your claims from paying.
*Denotes a required field. Please review the required fields before filling out the form.