ABA Therapy Program Provider Verification Form

Please fax or mail completed form and required attachments to:

888.617.0495

Premera Blue Cross PO BOX 91059 Seattle, WA 98111-9159

Section 1: General Information
A. Subscriber ID #: / B. Provider Name (Program Manager):
Last
/ First / M.I.
C. Social Security Number:
/ OR statements must use the SSN or TIN provided. / Tax Identification Number: / Either SSN or TIN may be provided; however, billing statements must use the SSN or TIN provided. / D. Date of Birth (mm/dd/yyyy):
E. National Provider Identifier Number (if available):
F. Service Location (no PO Box):
G. Billing Address:
H. Telephone Number: / I. Email Address:
Section 2: Required Qualifications
Please check one:
I certify that I am a Behavioral Analyst credentialed by the Behavioral Analyst Certification Board (BCBA)
·  Attach a copy of your certificate.
·  Renewals required as available.
·  Attach a copy of your W-9. / Other Licensed Provider (make a selection)
Medical Doctors (MD)
Doctors of Osteopathic Medicine (DO)
Nurse Practitioners (NP, ANP, ARNP, etc.)
PhD
Masters-Level Health Clinicians
Occupational, Physical and Speech Therapists
(when providing ABA services and practicing within their scope of license)
PsyD (Doctor of Psychology)
· 
Section 3: Security Data
In the past seven years, have you been released from prison or convicted of any crime? Include convictions for which you pleaded guilty or nolo contendre (no contest), paid a fine, received a suspended sentence and/or were incarcerated. Do not include minor motor vehicle violations and convictions that have been annulled, expunged, sealed, or pardoned by a court. Yes No
At any time in your life, have you ever been convicted of any criminal felony involving dishonesty or breach of trust or been convicted of an offense under Section 320603 of the Violent Crime Control and Law Enforcement Act of 1994, 18 U.S.C. Section 1033 (federal insurance crime law)? Yes No
If YES, please explain the circumstances of the conviction(s), including date, nature, town/city and state of each offense, disposition, and any other relevant information you may want to bring to our attention. Attach additional pages if necessary.
Section 4: Signature
I certify that all information I have provided in this application, including any attachments, is accurate and complete to the best of my knowledge. I understand that any false statement or misrepresentation of the information I have provided on my certification request or attachments will be grounds for rejection of my certification request or termination of my certification.
Applicant Signature: / Date (mm/dd/yyyy):

For questions, call Premera Customer Service at 877.995.2696.

026698 (06-2016) Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association