Instructions
Completing this credentialing application and receiving notification of your approved application is required before claims can be submitted.
To protect your privacy, this form will timeout after 15 minutes of inactivity. There is no ability to save your progress, so we suggest gathering the information outlined in the left navigation to have on hand as you are completing the form and to allow a minimum of 15 minutes to complete it.
Complete all sections that are applicable to you. Include all additional information requested. Fields that include an asterisk (*) indicate that a response is required. All other fields will be considered not applicable if left blank.
To go back to a previous section, use the previous link on the bottom of the page or by clicking the section in the left navigation. Any data you have entered will remain on page. Do not use your browser back button to go to a previous form section, doing so will result in the loss of all form data entered.
If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.