Provider Acquisition Process

Complete the form below for all provider acquisitions

Providers and practices who are going through an acquisition or are acquiring another practice are required to report any changes to Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

The form below is the easiest way to report acquisitions and buyouts and provide us with the necessary information to process your acquisition.

All acquisitions must be reported at least 60 days before the effective date.

Complete the Acquisition Form


Who should complete the form?

  • Entities who are acquiring a new provider/practice
  • Entities merging with another provider
  • Entities participating in a buyout
  • In- and out-of-network providers

What is required to complete the form?

  • Provider W-9 - accepted formats:  jpg jpeg png pdf
  • Official Documentation of Acquisition - accepted formats: jpg jpeg png pdf
  • Provider Roster - accepted formats: excel

Provider Acquisition Form

Provider Information


Primary Practice Information


Provider Roster









Practice Billing Information


Billing Contact


Required Documentation

Please have the following documents ready to email to us in the next step after completing your application. 

Note: Failure to provide the required documentation will result in your request being returned as incomplete.

  • Provider W-9 - accepted formats:  jpg jpeg png pdf
  • Official Documentation of Acquisition - accepted formats: jpg jpeg png pdf
  • Provider Roster (if you answered "yes" to the question above) - accepted formats: excel

Contract Information

Note: Completion of this form does not establish you or your practice as an in-network Blue Cross NC provider. Answers to these questions do not guarantee any particular contract outcome. Contract status is still subject to review.

"Yes" can only be selected for one of the options below, but you can choose "no" for both if desired.

OR