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For Blue Cross and Blue Shield of New Mexico contracted or non-contracted providers only.
All other providers — please contact your local Blue Cross and Blue Shield Plan.
Change requests for other Plans/States will not be forwarded.
Use this form if you are changing your group/practice information such as:
Fill out the fields below so we can update your provider record to ensure that you receive critical communications and efficient reimbursement.
If you need to change your tax identification number, please complete the following:
Solo and Group Providers
Facilities including Behavioral Health
Please tell us what information you are changing:
Effective date of change:
(Name, Phone, Email)
Accepting New Patients
Closed Accepting Existing Patients Only Existing Patients & Family Only
Mailing Address: (Correspondence)(Address, City, State, Zip Code, Phone/Fax)
Billing Address: (Billing/Payments)(Address, City, State, Zip Code, Phone/Fax)
(Address, City, State, Zip Code, Phone/Fax)
Office Days and Hours:
(include days and hours for each location)
*Tax ID Number:
*Tax identification number changes require the submission of a 147C letter. Attach documents below.
Office Manager: Physician: Billing Manager: Other/Who:
If you have questions, call your BCBSNM Network Services Provider Representative at 505-837-8800 or toll-free at 800-567-8540.
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an Independent Licensee of the Blue Cross and Blue Shield Association.
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