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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

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


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Pay To Information (where your checks will be mailed)

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Physical Location Information

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










Other Physical Location Information










Contact Information

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Documentation

We require a W-9 to ensure that we have accurate IRS reporting information on file. You can fax your W-9 to (215) 238-2537, or if you have an electronic copy on file, you can use the following browse option to attach and submit the file to us. We must receive your W-9 within 24 hours of your submission. If you do not provide your W-9 within 24 hours, we will deny your registration and you will have to resubmit.


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