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Ancillary Professionals

For changes related to You should
  • Tax ID
  • Joining/opening a new practice
  • Leaving your current practice
  • Adding a product to an existing contract
  • Discontinuing being a primary care provider with a panel of patients
Complete the Contract Update Form for your provider type.
  • Contract terminations (leaving all Blue Cross practices)
Submit a Standardized Provider Information Change Form.

The Change Form is managed by the Mass Collaborative.
  • Hospital affiliations
  • Accepting or not accepting new patients
  • Closing/re-opening your PCP panel (if you are a primary care provider)
Update your CAQH Provider Data Portal (formerly ProView) record or submit a Standardized Provider Information Change Form.

Diagnostic imaging privileging changes

If you Then
Have professional privileges No new professional privileging application is required.
Have technical privileges but are moving, adding a site, or joining a new practice Go to the Privileging page and download the applicable privileging application.
Are not currently approved for either professional or technical privileging