Provider Maintenance Form

The Provider Maintenance Form (PMF) is to be used by New York individual physicians, practitioners, professionals and group practices to request changes to their practice profiles with Empire BlueCross BlueShield

It is critical that our members receive accurate and current data related to provider availability. Changes to provider records that are affiliated with group contracts must be reported to and submitted by the practice manager or other designated person of authority at the group. Changes to individual contracts may be made at the direction of the contracted physician. All requests must be received by Empire BlueCross BlueShield 45 days prior to the change/update unless you are providing notice of termination from our network, then requests must be received 60 days prior to change. Any request received by Empire BlueCross BlueShield less than 45 days prior to the change may be assigned a future effective date. Contract terms may also supersede the requested effective date. Submit the PMF to Empire BlueCross BlueShield of any changes to the provider/practice name, practice/mailing address, tax identification number, hospital privileges, phone and fax numbers, practice office hours, provider leaving/retiring, provider joining the practice, practice accepting new patients, handicapped accessibility, specialties or languages offered.

If you are a HOSPITAL BASED PROVIDER please contact the Provider Maintenance Department to make changes to your information.

Please follow these instructions when submitting the PMF:

1. Complete all applicable sections. The form has multiple options (+) for changes. Complete only the sections applicable to the requested change(s). NOTE: This form will time out after 30 minutes of activity or inactivity and all entries made but not yet submitted will be lost.
2. Before clicking on the 'Submit' button at the bottom of the PMF, indicate if the change(s) require a valid W-9 (such as ALL Tax ID changes), as the W-9 must be submitted with the PMF through the attachment section along with any other attachments necessary to fulfill the request.

Reason for Submitting this Form

• 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 office hours or days of operation
• Name change for individual physician/practitioner
• Change in your acceptance of new patients
• Change in your Medication Assisted Treatment (MAT)
• Update or add your Billing NPI
• Update or add your email address
• Change your practice or group name
• Add or change provider's hospital privilege(s)
• Add or change provider's language(s) spoken

• Change your Tax Identification Number (TIN) or ownership of group practice (W-9 Required)
• Termination of your Provider Participation Agreement
• Add or terminate PT, OT, ST, or audiologist to or from existing ancillary contracted group (Ancillary providers only)
• Add or change provider's areas of expertise (behavioral health providers only)
• Add or change your provider specialty or type (change may require provider to be credentialed)

CLICK HERE to make one or more of the above changes.

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