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 Cross Blue Shield of Western 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 Cross Blue Shield of Western 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.
• 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.