Blue Cross Community OptionsSM Provider Survey

Blue Cross and Blue Shield of Illinois (BCBSIL) is enhancing its provider file to include specific areas of expertise for Blue Cross Community MMAI (Medicare-Medicaid Plan)SM, Blue Cross Community ICPSM, or Integrated Care Plan, and Blue Cross Community Family Health PlanSM (FHP) providers. This enhancement will help us more accurately represent the services you provide to our members. Please complete and submit the survey below so that we may update our records accordingly. Only check the boxes that apply to your practice. If you provide services at multiple locations, the areas of expertise you select will be applicable to all locations. Contact with questions.

Thank you for your participation!
Section 1: Demographics

Practice Location Address:*
Office Name
Address 1
Address 2
City State Zip
Contact Telephone Number
Provider First Name:*
Provider Last Name:*
National Provider Identifier (NPI)*
Section 2: Treatment Areas*
Items marked with an asterisk (*) are mandatory.