Provider Information Management Forms

Provider Information Management forms are used to maintain provider accounts as well as begin the process to join the Highmark Blue Shield of Northeastern New York network for new practitioners and offices. Please carefully read and follow the instructions contained within the individual form for submission. (If you are unsure of which form to use, CLICK HERE.)

Electronic Forms 

Electronic Forms are submitted directly to Highmark Blue Shield of Northeastern New York via this website. You may need to upload documentation/provide additional research during parts of this form. Please feel free to take the time to research these items and input the responses as the form will not time out.  

>> Provider Directory Update Form
Providers should utilize this electronic form to update a practitioner or group name, address, phone number, email, website address, and specialty or to terminate a practitioner from a group. This form has been created for in-network provider use in order to comply with the No Surprises Act that was signed into law in December 2020. Changes to these elements will not be accepted via any other electronic form.

  • Request for New Practice (Assignment Account) - Use this form to:
    • Request to create a new practice account
    • Update existing participating practice Tax ID
  • Request to Add a New Practitioner to an Existing Participating Practice - Please use this form when needing to update practitioner’s affiliation to an existing participating practice (Assignment Account).
  • Advanced Practice Provider (APP) Enumeration Form - Use this form to enroll NPs, PA-Cs, CRNAs and RNFAs with your participating practice.
  • Contract Upload Form - Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned.
  • Name Verification Form - Please use this form if a practitioner's name on any document is different than what appears on their current medical license. They may also update the information in the Other Names section of their CAQH profile.
  • Nurse Practitioner Agreement/Acknowledgement - Participating NPs must use this form to change their supervising physician. (Note - Supervising physicians must also be participating with Highmark.)
  • Supervision Data Form - Participating PA-Cs, CRNAs and RNFAs must use this form to change their supervising physician. (Note - Supervising physicians must also be participating with Highmark.)
  • NPI Change Form - Use this form to update an existing individual participating provider or group NPI.
  • Facility-Based Provider Affirmation Statement - Please use this form when adding a practitioner to an existing assignment account when the services provided to members services by the networks are delivered exclusively in a participating skilled nursing facility, participating ambulatory surgery center, inpatient hospital and/or freestanding inpatient or outpatient facility setting and for members only because they are directed to the facility setting.
  • Out of State Address Change Form for Professional Providers - This electronic form should be used for providers outside of Delaware, New York, Pennsylvania, and West Virginia to create a billing vendor or to update an address on an existing billing vendor.
  • Request to Terminate a Contracted Network - Please only use this form to terminate the group contract from the following Highmark networks: All Commercial Networks, All Medicare Networks, or All Medicaid Networks.
    • This form may not be used to terminate an individual commercial network. It may only be used to terminate the groups of networks listed above.
Last updated on 3/6/2024 9:17:59 AM


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