Group Practitioner Enrollment Form

All provider groups must complete a Group Enrollment form in order to included in the Blue Cross NC provider network.

Forms required for enrollment to be processed:

  • W9 (only required if you do not have a Type 2 NPI

1 Tax Info 2 Group Info 3 Location 4 Practitioner Info 5 Enroll
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Join our Network!

Thank you for your interest in joining Blue Cross and Blue Shield of North Carolina (Blue Cross NC)’s growing network of physicians, health care professionals and facilities who share our commitment to improving the health and well-being of our members and communities.

The first step is to enroll your provider group! 

Important Tips:

1.  Tax Information

To ensure compliance with the Internal Revenue Service (IRS) regulations, we must have your tax identification information to process your application. When submitting this enrollment application, please be sure to include a completed W-9 containing the billing entity information. Enrollment applications without a completed W-9 Form will not be processed.

Steps to send your W-9 Form:

  1. Download the W-9 Form and complete it in its entirety.
  2. Email completed W-9 Form to
  3. Include the following information in the email subject line:
    • Provider Group W-9 Form
    • Provider Group Name
    • National Provider Identifier (NPI) Type II Number

Example: Provider Group W9 | Provider Group Name | NPI Type II