Indicate whether you are a Medical Professional (any individual Provider that provides healthcare services in the U.S), Medical Group (two or more Medical Professionals, and those claiming by or through them, who practice under a single taxpayer identification number), or a Medical Organization (any association, partnership, corporation or other form of organization—including without limitation independent practice associations and physician hospital organizations – that arranges for care to be provided to Blue Plan Members by Medical Professionals organized under multiple taxpayer identification numbers) and complete the information below.