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Nonparticipating Professional 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 Professional Provider. If you are going to submit claims as a Facility or Ancillary entity, please fill out the Non-Par Facility/Ancillary 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 previously submitted a claim to Independence Blue Cross, please enter your Provider number.


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

Type 1 (individual)
Type 2 (organization)













Billing Information










Physical Location Information










Mailing Address (If different than Billing or 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.