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Nonparticipating Facility/Ancillary 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: 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.

Provider Information


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










Pay To Information (where your checks will be mailed)










Physical Location Information










Mailing Address (If different than Pay To or Physical Location Information)










Other Physical Location Information










Contact Information









Documentation

We require a W-9 to ensure that we have accurate IRS reporting information. Please attach a 1MB or smaller copy of your W-9 to submit your request. Without a W-9, we cannot process your request. Thank you.