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Nonparticipating Nonmedical/Atypical 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: If you are a nonparticipating provider with Independence Blue Cross, please use the proper registration form (based on your provider type). This form is for nonpar nonmedical/atypical providers (e.g., nonmedical transportation).

*Denotes a required field. Please review the required fields before filling out the form.

Provider Information

If you have previously submitted a claim to Independence Blue Cross, please enter your Provider number.








Pay To Information










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 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.