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    Combined Participation Agreement

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    Aurangzeb Jadoon
    A doctor is signing agreements to participate in several Blue Cross Blue Shield of Michigan networks, including the Traditional network, TRUST PPO network, Medicare Advantage PPO network, and Blue Preferred Plus network. The agreements will not take effect until the doctor completes the credentialing process successfully. Once credentialed, the doctor will receive letters notifying them of the effective dates for each applicable network affiliation.

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    © All Rights Reserved
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    Combined Participation Agreement

    Uploaded by

    Aurangzeb Jadoon
    129 views1 page
    A doctor is signing agreements to participate in several Blue Cross Blue Shield of Michigan networks, including the Traditional network, TRUST PPO network, Medicare Advantage PPO network, and Blue Preferred Plus network. The agreements will not take effect until the doctor completes the credentialing process successfully. Once credentialed, the doctor will receive letters notifying them of the effective dates for each applicable network affiliation.

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    A doctor is signing agreements to participate in several Blue Cross Blue Shield of Michigan networks, including the Traditional network, TRUST PPO network, Medicare Advantage PPO network, and Blue Preferred Plus network. The agreements will not take effect until the doctor completes the credentialing process successfully. Once credentialed, the doctor will receive letters notifying them of the effective dates for each applicable network affiliation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    129 views1 page

    Combined Participation Agreement

    Uploaded by

    Aurangzeb Jadoon
    A doctor is signing agreements to participate in several Blue Cross Blue Shield of Michigan networks, including the Traditional network, TRUST PPO network, Medicare Advantage PPO network, and Blue Preferred Plus network. The agreements will not take effect until the doctor completes the credentialing process successfully. Once credentialed, the doctor will receive letters notifying them of the effective dates for each applicable network affiliation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    A nonprofit corporation and independent licensee

    of the Blue Cross and Blue Shield Association

    Individual Signature Document Your signature below establishes your commitment to be legally bound by the
    terms and conditions of the Practitioner Agreement(s) you check below.
    Please note:
    Managed care network affiliations do not become active until the credentialing process has
    been successfully completed and the relevant contracts have been signed.
    Until you are formally affiliated with these networks, you are regarded as an out of network
    practitioner and out of network claims sanctions may apply.
    BCBSM Physician or Professional Practitioner

    BCBSM Practitioner Traditional Agreement (WP 7669 JUN 16) incorporated by reference.
    The effective date of your participation in Traditional will be as of the date of your signature
    below, provided you meet all applicable enrollment criteria.

    BY:
    DANIEL J. LOEPP
    President and CEO
    Blue Cross Blue Shield of Michigan
    Combined Participation Agreement

    BCBSM TRUST (also known as TRUST PPO) Network Practitioner Affiliation Agreement
    (WP 7637 JUN 16) incorporated by reference.
    BCBSM Medicare Advantage PPO Provider Agreement (WP 10380 SEP 15) and
    Practitioner Attachment (CF 10381 JUL 08) incorporated by reference.
    Blue Preferred Plus Practitioner Affiliation Agreement (Practitioner Affiliation Agreement for
    Blue Preferred Plus (PA-Individual Practitioner-BPP).
    Blue Preferred Plus Individual Anesthesiology Services (PA-Individual Practitioner-BPP-Anes).

    The TRUST Network Practitioner Affiliation Agreement, the Medicare Advantage Provider
    Agreement and the Blue Preferred Plus Practitioner Affiliation Agreement will become effective
    once you have successfully completed the credentialing process. You will receive a letter
    notifying you of the outcome of the credentialing process and the effective date of your affiliation
    with each,applicable network.

    The Signatures on the letter you receive will serve as BCBSM's countersignature on the
    Agreement, thereby creating a final contract between you and BCBSM. You will then be
    formally affiliated with the applicable network and be regarded as an in network practitioner.

    Physician or Professional Practitioner

    AAMER ABBAS 1508975772

    Individual Name Individual NPI

    01/05/2024

    Signature Date

    Pending
    Michigan Professional License Number
    Please return this
    Signature Document to:
    Provider Enrollment and Data Management
    WF 14545 JUL 18 Blue Cross Blue Shield of Michigan
    Fax to 866-900-0250

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