Dentist Profile Form / W-9 Form

A Dentist Profile form needs to be completed if either of the following apply:

• Existing Blue Cross of Idaho provider adds a new location
• Existing Blue Cross of Idaho provider leaves one location and moves to another location
• New Blue Cross of Idaho provider is added to an existing practice

A Dentist Profile form and a W-9 needs to be completed if either of the following apply:

• New Blue Cross of Idaho provider sets up a new practice
• Existing Blue Cross of Idaho provider adds a new practice with a new tax identification number

It is very important that you include all of the information requested on the Dentist Profile form. Once completed, please return the form to Blue Cross of Idaho Dental Services via fax @ 208-286-3575 or mail to:

Blue Cross of Idaho
PO Box 7408
Boise, ID 83707