Instructions for fax cover sheet
We cannot accept handwritten forms. Do not hand write anywhere on the forms, otherwise
processing will be delayed.
To ensure forms are processed timely, please adhere to the following instructions:
For individual practitioners
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 1 NPI (National Provider Identifier)
10 digit state license number
When adding an individual to an existing group, be sure to fax a group change form
For allied providers
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 2 NPI (National Provider Identifier)
Tax identification number
For professional group practices and facilities
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 2 NPI (National Provider Identifier)
Tax identification number
Instructions for document submission
1. Fax cover sheet must be the first page of your form submission.
2. Fax the registration form and attachments (i.e., signature documents) to 1-866-900-0250.
Be sure to fax the registration information separately for each provider. (For example: If
you register two or more providers, you must send a fax for each provider. They cannot be
bundled into one fax transmission.).
Questions? Call 1-800-822-2761
W008950
WF 10582 JAN 23 Page 1 of 12
NEW GROUP ENROLLMENT FORM
FAX COVER SHEET
FOR DOCUMENTS
IMPORTANT: Attach this page to the top of your document
to avoid processing delays.
Fax To: 866-900-0250 Provider Enrollment
From:
Date:
Form Number: 10582
Type 2 NPI: 1104122365
Tax Identification Number: 783746783
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
WF 10582 JAN 23 Page 2 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 1: Demographic Data *denotes a required field
*Group name TEXAS HEALTH PHYSICIANS GROUP
*Group specialty Pediatrics
*County where your primary address is located DALLAS
*Website www.texashealth.org
*EIN/Tax ID number 783746783
*EIN/Tax name as indicated on Internal Revenue
Service document TEXAS HEALTH PHYSICIANS GROUP
*Tax exempt Yes No
Are you a Retail-based Health Clinic? Yes No
Are you a Community Mental Health Center Yes No
Are you a Federally Qualified Health Center? Yes No
Are you an Indian Health Service Provider? Yes No
If yes, are you limited to tribal members only? Yes No
Are you a Student Health Services Provider? Yes No
Are you considered an Essential Community Provider under the Affordable Care Act?
Yes No
See Section 7 for additional information on participation?
Are you applying as an Urgent Care Center? Yes No
If you are an incorporated individual billing with your Type 2 NPI, you must also complete a New Practitioner Enrollment
form to register your Type 1 NPI for billing purposes.
Section 2: Requested networks
Requested effective date - The actual effective date will be determined based on the provisions in the applicable
Participation/Affiliation agreements. Your requested effective date cannot precede the date the group was formed as
a bona fide legal entity. Important: Along with the application, it is necessary to complete and submit the signature
document appropriate for your provider type. For each network you wish to participate in, be sure to place a check
mark by the appropriate affiliation agreement, sign the signature document, and submit it along with this form.
BCBSM and BCN do not permit retroactive effective dates in managed care networks.
Select networks you are apply to:
BCBSM networks Requested networks
Participating Nonparticipating
Traditional
Requested effective date:
Participating Nonparticipating
Vision
Requested effective date:
Participating Nonparticipating
Hearing
Requested effective date:
BCN networks Requested networks
BCN Commercial
BCN AdvantageSM HMO
WF 10582 JAN 23 Page 3 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 3: Address data *denotes a required field
Primary office address (Must be an address where health care services are rendered and may be published
in BCBSM/BCN provider directories)
*Street address
PO BOX 975341
*City *State ZIP code
DALLAS TX 75397
Primary telephone number must be a phone number patients can call to make an appointment
*Primary telephone number (972) 791-1224 Fax number
Payment address
Street Address
9250 AMBERTON PKWY
City State Zip Code
DALLAS TX 75243
Mailing address
Street Address
PO BOX 975341
City State Zip Code
DALLAS TX 75397
Contact information (Please provide the name and contact information of a person who can answer questions
about information in this application)
*First name Last name
SHAWN D PARSLEY
*Telephone number Fax number
(214) 860-6300 extension
E-mail address Preferred method of contact?
Email US Mail
Medical Records Request (MRR)
Street Address
PO BOX 975341
City State Zip Code
DALLAS TX 75397
Contact Name - First Middle Last
JOHN PETTER
Telephone Fax Email
(972) 791-1224
WF 10582 JAN 23 Page 4 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 3: Address data (continued)
Additional address - Accessibility
*Handicap accessibility: Yes No *Accessible by bus: Yes No
*Primary address - Office Hours
Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open Time 9am 9am 9am 9am 9am 9am Holiday
Close Time 5pm 5pm 5pm 5pm 5pm 5pm Holiday
Does your group provide in-home visits? Yes No
Section 3a: Work Setting (Required):
Work setting provides information on whether primary care, specialty care, or mixed services are provided at the group.
Work setting status at the group is determined by the work setting status of the affiliated practitioners.
Work Setting (select only one)
All practitioners are performing primary care services at this
Primary Care Work Setting
location.
All practitioners are functioning as specialists for all
Specialty Care Work Setting
non-primary care services at this location.
Some practitioners are performing primary care services and
Mixed Work Setting others are functioning as specialists for all non-primary care
services at this location.
Disclaimers:
The primary care work setting indicator should not be confused with a BCN or PGIP practitioner that is a contracted PCP.
The primary care work setting indicator does not make a practitioner a BCN PCP or PGIP PCP. This does not impact or
replace your contract status as a BCN/PGIP PCP. If a practitioner selects a primary care work setting this does not impact
your contracted network status.
Section 4: Services
Telehealth Services
Telehealth - Audio/Visual Telehealth - Telephone Only
WF 10582 JAN 23 Page 5 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 4: Services (continued)
Services: Select the services your group performs
Radiology Services:
Bone Density Mobile Unit Oncology
CT Scan MRI PET Scan
Diagnostic Testing MRI of Breast Read-only
Fluoroscopy MRI - Open Routine Xray
Mammography Nuclear Medicine Ultrasound
Sleep Testing Services:
Home Testing Yes No
If yes, are you accredited by the American Academy of Sleep Medicine? Yes No
In-Center Sleep Testing Yes No
If yes, are you accredited by the American Academy of Sleep Medicine? Yes No
If ‘Yes’ is selected, attach a copy of your AASM accreditation certificate.
If it is not attached, your request may be denied.
Telehealth Services:
Select the following telehealth services you provide:
Telehealth Offered-audio and visual
Telehealth Originating Site
Real-time online visit/e-visit
Behavioral Health Services
Select the following Telehealth services you provide:
Telehealth Services
Telehealth - Audio/Visual Telehealth - Telephone Only
Select Age Ranges Treated:
0-12 (Child) 3-17 (Adolescent) 18-64 (Adult) 65+ (Geriatric) Other:
Check Counseling Services Provided
Mental Health Outpatient Services
Substance Use Outpatient Services
SAMHSA certified Opioid Treatment Program (OTP) - select applicable programs below:
Are you currently accepting new patients for SAMHSA Certified Opioid Treatment Program? Yes No
WF 10582 JAN 23 Page 6 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 4: Services (continued)
In an effort to assist us match patient need to available providers, please indicate your facility’s special areas of interest
below. Select no more than ten total treatment specialties and treatment modalities. We will use this information in directing
members for specific services. Our expectation is that your practice is open and accepting new cases if you indicate
specialties below.
By selecting the below specialties or modalities, you are attesting that you or your staff have received specialized
education, training, and supervision in that specialty/modality.
Select Treatment Specialties Appropriate Treatment Modalities
ADD / ADHD Add ADOS Testing (trained / qualified) for Autism Add
Anxiety, Phobias and Related Disorders Add Adult Intensive Services (AIS) Add
Autism Add Applied Behavior Analysis (ABA) for Autism Add
Bereavement / Grief / Loss Add Bariatric Evaluations Add
Disorders of Childhood & Adolescence Add Brief Dynamic Therapy Add
Dissociative Disorders Add Children’s Intensive Services (CIS) Add
Eating and Feeding Disorders Add Cognitive Behavioral Therapy (CBT) Add
Gambling Disorder Add Dialectical Behavioral Therapy (DBT) Add
Gaming (compulsive) Add Electroconvulsive Therapy (ECT) Add
Gender / Transgender Identification Add Exposure Response Prevention (ERP) Therapy Add
Geriatric / Older Adult Disorders Add Eye Movement Desensitization Reprocessing (EMDR) Add
HIV / AIDS Add Interpersonal Therapy Add
LGBTQ+ Add Medication Assisted Treatment (MAT) for Opioid Use Add
– Suboxone/Buprenorphine
Mood Disorders Add
Obsessive Compulsive and Related Disorders Add Medication Assisted Treatment (MAT) for Opioid Use Add
– Vivitrol/Naltrexone
Opioid Use Disorders Add
Pain Management Add NAVIGATE Add
Personality Disorders Add Neurofeedback (for ADHD only) Add
Pregnancy Challenges Add Neuropsychological Testing Add
Psychotic Disorder Add Psychological Testing Add
PTSD / Trauma Disorders Add Transcranial Magnetic Stimulation (TMS) Add
Selective Mutism Add
Sexual Addiction Add
Sexual Dysfunction Add
Substance Use Disorders Add
Traumatic Brain Injury Add
WF 10582 JAN 23 Page 7 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 5: Additional practice locations
(Must be an address where health care services are rendered and may be published in BCBSM and BCN provider
directories)
If you have additional locations, please list and attach separately.
Street Address
#1 City State ZIP Code
Telephone Number Fax Number
Additional address - Accessibility
*Handicap accessibility: Yes No *Accessible by bus: Yes No
Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open Time
Close Time
Street Address
#2 City State ZIP Code
Telephone Number Fax Number
Additional address - Accessibility
*Handicap accessibility: Yes No *Accessible by bus: Yes No
Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open Time
Close Time
Street Address
#3 City State ZIP Code
Telephone Number Fax Number
Additional address - Accessibility
*Handicap accessibility: Yes No *Accessible by bus: Yes No
Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open Time
Close Time
WF 10582 JAN 23 Page 8 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 6: Add group members
If you have additional practitioners, please duplicate this page for each practitioner and respond to the
questions as indicated.
Name (First Name , Last Name) Degree NPI
AAMER ABBAS 1508975772
List practice address #’s from Section 5, where this provider practices (e.g., Primary, 1, 2, 3).
Also check the appropriate box about each individual’s practice location.
Work Setting (required)
Work setting provides information on whether primary care, specialty care, or mixed services are provided
at the group. Work setting status at the group is determined by the work setting status of the affiliated
practitioners.
Primary Care Work Setting: Is the practitioner performing primary care services at this Yes
location?
Specialty Care Work Setting: Is Practitioner functioning as a specialist for all non-primary Yes
care srvices performed at this location?
Disclaimer: If a practitioner is performing both primary care and specialty care services at the same type 2 NPI
they will automatically be defaulted to a primary care work setting. The primary care work setting indicator
should not be confused with a BCN or PGIP practitioner that is a contracted PCP. The primary care work setting
indicator does not make a practitioner a BCN PCP or PGIP PCP. This does not impact or replace your contract
status as a BCN/PGIP PCP. If a practitioner selects a primary care work setting this does not impact your
contracted network status.
Can a patient make an appointment to see this practitioner Yes No
on a regular basis at this location?
Does this practitioner cover or fill-in for colleagues within Yes No
the same medical group on a needed basis?
Primary Location: 75397-6756
Does this practitioner read tests or provide other services Yes No
but does not see patients at this location?
Other:
Can a patient make an appointment to see this practitioner Yes No
on a regular basis at this location?
Does this practitioner cover or fill-in for colleagues within Yes No
75455-2338 the same medical group on a needed basis?
Location #2
Does this practitioner read tests or provide other services Yes No
but does not see patients at this location?
Other:
WF 10582 JAN 23 Page 9 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 6: Add group members (continued)
Name (First Name , Last Name) Degree NPI
AAMER ABBAS 1508975772
List practice address #’s from Section 5, where this provider practices (e.g., Primary, 1, 2, 3).
Also check the appropriate box about each individual’s practice location.
Work Setting (required)
Work setting provides information on whether primary care, specialty care, or mixed services are provided
at the group. Work setting status at the group is determined by the work setting status of the affiliated
practitioners.
Primary Care Work Setting: Is the practitioner performing primary care services at this Yes
location?
Specialty Care Work Setting: Is Practitioner functioning as a specialist for all non-primary Yes
care services performed at this location?
Disclaimer: If a practitioner is performing both primary care and specialty care services at the same type 2 NPI
they will automatically be defaulted to a primary care work setting. The primary care work setting indicator
should not be confused with a BCN or PGIP practitioner that is a contracted PCP. The primary care work
setting indicator does not make a practitioner a BCN PCP or PGIP PCP. This does not impact or replace your
contract status as a BCN/PGIP PCP. If a practitioner selects a primary care work setting this does not impact
your contracted network status.
Can a patient make an appointment to see this practitioner Yes No
on a regular basis at this location?
Does this practitioner cover or fill-in for colleagues within Yes No
75397-6756 the same medical group on a needed basis?
Primary Location:
Does this practitioner read tests or provide other services Yes No
but does not see patients at this location?
Other:
Can a patient make an appointment to see this practitioner Yes No
on a regular basis at this location?
Does this practitioner cover or fill-in for colleagues within Yes No
75455-2338 the same medical group on a needed basis?
Location #2
Does this practitioner read tests or provide other services Yes No
but does not see patients at this location?
Other:
If you have additional practitioners, please duplicate this page for each one and respond to the questions
as indicated. Once enrolled, you can also log in at Availity.com to access Provider Enrollment and Change
Self-Service.
If applying to participate with Traditional, Vision, Hearing, BCN Commercial and/or BCN AdvantageSM HMO,
each group member must sign the Group Practice Agency Authorization and Acknowledgment Form.
It is understood that Group, its representative, or delegate is responsible for having each group member/
individual practitioner execute the Group Practice Agency Authorization and Acknowledgment Form. Group
must retain copies of such executed form and provide to BCBSM upon request.
WF 10582 JAN 23 Page 10 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 7: Group representative certification
The members of TEXAS HEALTH PHYSICIANS GROUP have certified.
(Name of Group)
Name of group representative SHAWN D PARSLEY to
act as agent and attorney in fact for all group members. The group representative, or his/her delegate, has
express authority to submit claims for payment to BCBSM and/or BCN, and group members have given the
representative authority to submit claims and receive payment on their behalf for covered services provided to
BCBSM and/or BCN subscribers and members. It is understood and agreed that claims will be submitted only
for covered services which are medically necessary, and only for services personally performed or personally
supervised by and in the presence of a group member. In the event a BCBSM or BCN audit results in a
recovery effort against any group member, the member and the group will be jointly and severally liable for that
debt so long as the member was affiliated with the group on the dates of service included in the audit.
It is also understood that this is a continuing authorization and that data on claim forms are entered with the same
authority, accuracy and effect as though executed by the group member providing the covered service. This
authorization will remain in effect until terminated or modified by the representative’s written notice to BCBSM
Provider Enrollment Department or by BCBSM and/or BCN upon written notice to the group representative.
If participating with BCBSM, I certify:
(1) That I have notified and obtained assent by group members to the terms and conditions of the BCBSM
Participation Agreement(s) signed on their behalf;
(2) That the name(s) and license information entered on this application are those of group members for which
a Group Provider Identification Number is to be issued and used, and
(3) I will notify BCBSM Provider Enrollment department in writing within 10 days of group member enrollment
changes, including additions and terminations of group members.
(4) That all of the group’s shareholders are professionally licensed in at least one (1) of the professional services
provided by the group.
If the group qualifies as an Essential Community Provider, the following apply:
(5) All providers within group are affiliated with BCBSM as a TRUST and SE Michigan Exclusive Provider
PRACTITIONER, if eligible for participation in that network or as a TRADITIONAL PRACTITIONER in
instances where the PROVIDER is not eligible to participate in the TRUST network.
(6) All new providers added to group will be affiliated with BCBSM as a TRUST PRACTITIONER, if eligible for
participation in that network, or as a TRADITIONAL PRACTITIONER in instances where the PROVIDER is
not eligible to participate in the TRUST network.
(7) That payment will be governed by the terms of the relevant individual affiliation agreement held by the
provider that rendered the service.
I certify that the information contained in this application is true and complete.
Group representative signature: Date: 01/06/2024
WF 10582 JAN 23 Page 11 of 12
NEW GROUP ENROLLMENT FORM
Tax Identification Number Type 2 National Provider Identifier
783746783 1104122365
Section 8: Application signature
Have you ever been convicted of, plead guilty to, or nolo contendere to any felony?
No Yes (Insert nature of offenses)
In the past ten years, has any professional corporation, partnership, limited liability company or any other such
entity in which you own an equity interest (directly or indirectly) and/or serve any management or leadership
function (including, but not limited to, acting as a manager, board member, director, or executive) been
convicted of, plead guilty to, or plead nolo contendere to any misdemeanor or been found liable or responsible
for any civil or criminal offense?
No Yes (Insert nature of offenses)
I certify that the information contained in this application is true and complete. I will notify Blue Cross and Blue Shield
of Michigan and Blue Care Network immediately in writing of changes affecting this data. If I am a practitioner in
training, I will not report services that are related to my training program and rendered at the address from which I am
training. Should I re-enter training, I will notify BCBSM and BCN.
For providers applying to be Traditional non-participating providers, the authorized signer agrees on behalf of itself
and the provider on whose behalf the authorized signer is acting, to adhere to BCBSM’s Billing Guidelines for Non-
Participating Providers. These Guidelines include, without limitation, the requirement to permit BCBSM or its designee
physical access to the provider’s premises to review and/or copy for any permissible purpose any and all medical
and billing records submitted by the provider or its billing agent; and the requirement that the provider accept
BCBSM’s payment as payment in full for services rendered to a BCBSM member when the provider has indicated
that it will accept assignment of payment on the member’s behalf, will participate with BCBSM on a particular claim,
or has otherwise indicated that he/she wishes to receive payment directly from BCBSM and with the exception of
any applicable deductibles, copayments, or co-insurance amount, not balance bill the member for the difference
between BCBSM’s payment and the provider’s charged amount.
*Print or Type Name *Authorizing Signature/Title *Date
TEXAS HEALTH PHYSICIANS GROUP 01/05/2024
Before submitting,
1) Have you completed Section 6 of this form?
2) Have you completed the Group Signature Document and the SS-4, or IRS Payment Stub, to submit
along with this form?
WF 10582 JAN 23 Page 12 of 12
