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Welcome to Blue Cross and Blue Shield of Georgia

Provider Maintenance Form

The Provider Maintenance Form (PMF) should be used by Georgia physicians, providers and professionals to submit demographic or other practice changes to Blue Cross and Blue Shield of Georgia.

Changes to provider records that are affiliated with group agreements must be requested from the practice manager or designated person of authority. Changes to individual contracts may be made at the direction of the specific physician. All requests must be received 30 days prior to change/update. Any request received with less than 30 days notice may be assigned a future effective date. Contractual guidelines may supersede effective date request. Please provide 90 days notice of termination from our network.

Please be certain to use the following instructions when making any change(s) requiring a new IRS Form W-9, as the Form W-9 must be submitted SEPARATELY from the Provider Maintenance Form (PMF):

  1. Complete all applicable sections of the PMF. This form has multiple options (+) for changes. Complete only the applicable sections to which the change(s) request is needed.
  2. Before clicking the 'Submit' button at the bottom of the PMF, note if the change(s) require a new Form W-9 or other attachment.
  3. Complete a new IRS Form W-9 or other attachments submit by emailing, faxing or mailing to one of the following:

Email: providersupport@bcbsga.com

Fax: (877)551-6184

Mail:

    Blue Cross and Blue Shield of Georgia
    Mail Code GAG006-0010
    3350 Peachtree Rd
    Atlanta, Georgia 30326

Click here for additional form completion instructions

Reason for Submitting this Form

Option 1

  • Change or update your patient age and gender preference
  • Change your practice address or phone number
  • Add a new location to your practice
  • Close a practice location
  • Provider is leaving a group
  • Remove a provider from a location
  • Change your payment and remittance address
  • Change your correspondence address
  • Change your office hours or days of operation
  • Name change for individual physician/practitioner
  • Change in your acceptance of new patients
  • Update or add your NPI
  • Update or add your email address
  • Add or change provider's areas of expertise (behavioral health providers only)
  • Add or terminate PT, OT, ST, RD or audiologist to or from existing ancillary contracted group (excludes physician group practices)
CLICK HERE to make one or more of the above changes

Option 2

  • Change your Tax Identification Number (TIN) or ownership of group practice
  • Add or change your provider specialty or type
  • Termination of your Provider Participation Agreement
  • Change your practice or group name
  • Change your IPA or PHO affiliation
  • Add or delete covering/back-up physicians


CLICK HERE to make one or more of the above changes

Option 3

CLICK HERE only if you need to make one or more changes in both Options 1 and 2