HIV-Experienced Provider Identification

Audience: Physicians, Nurse Practitioners and Physician Assistants

Excellus BlueCross BlueShield is required by the New York State Department of Health to identify participating practitioners who have experience treating HIV/AIDS patients and to make this information available to members in our provider directory.

An HIV-experienced practitioner is defined as:

1. A medical doctor, nurse practitioner or physician assistant providing ongoing direct clinical ambulatory care to at least 20 HIV-infected persons who are being treated with antiretroviral therapy in the preceding 12 months, or


2. A practitioner who has met the criteria of one of the following accrediting bodies:
   • The HIV Medicine Association (HIVMA) definition of an HIV-experienced provider
   • HIV specialist status accorded by the American Academy of HIV Medicine (AAHIVM)
   • Advanced AIDS Credited Registered Nurse Credential given by the HIV/AIDS Nursing Certification Board (HANCB)

We need your help. If you meet one of the above definitions, please complete the HIV-Experienced Provider Attestation Form included with this mailing and fax it to the number provided on the form at your earliest convenience, but no later than March 1, 2023. This will help to ensure that your information is included in future Provider Directory updates to assist our members in locating HIV/AIDS-experienced physicians. Thank you for your assistance!

Please share this important information with all practice locations or corporate offices. If you have questions, please contact your Provider Relations representative.

HIV-Experienced Provider Attestation Form

I attest that I am an HIV-experienced practitioner based on the following criteria:

1. A medical doctor, nurse practitioner or physician assistant providing ongoing direct clinical ambulatory care to at least 20 HIV-infected persons who are being treated with antiretroviral therapy in the preceding 12 months, or


2. A practitioner who has met the criteria of one of the following accrediting bodies:
   • The HIV Medicine Association (HIVMA) definition of an HIV-experienced provider
   • HIV specialist status accorded by the American Academy of HIV Medicine (AAHIVM)
   • Advanced AIDS Credited Registered Nurse Credential given by the HIV/AIDS Nursing Certification Board (HANCB)

(List all HIV-experienced practitioners in your practice. Photocopy this form if more space is needed.)

Print Name:     _________________________________________________________________

Signature:        ________________________________________________________________

NPI:                  ________________________________________________________________

Print Name:     _________________________________________________________________

Signature:        ________________________________________________________________

NPI:                  ________________________________________________________________

Print Name:     _________________________________________________________________

Signature:        ________________________________________________________________

NPI:                  ________________________________________________________________

Print Name:     _________________________________________________________________

Signature:        ________________________________________________________________

NPI:                  ________________________________________________________________

Please complete by March 1, 2023, and fax to 
Excellus BCBS at 1-800-676-6285.