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Health and Vision Provider Account Management

Type of Request
 This is your 6 or 7-digit ID assigned by Pacific Blue Cross
 This is the date when this practitioner started/stopped working at this location
Practitioner Type
 Personal email address of the practitioner only and CANNOT be the same as the PRIMARY ADMINISTRATOR email address for the clinic
 Registration number with College indicated above
 Effective date of your registration with the above Regulatory/Licensing body
Provider Location
Signature

Blue Shield

Blue Shield is a registered trade-mark of Blue Cross Blue Shield Association
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