If you have had a recent change in whether or not you are seeing new patients at any location, please complete this form,
and we will update your le.
If making changes to multiple locations with the same EIN, please attach a list of all locations the change applies to. Submit
a separate form for each EIN.
Yes, I am accepting new patients.
No, I am not currently accepting new patients.
If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.
Provider Information
Provider Name Individual NPI
Clinic/Facility Name EIN
Address
City State Zip
Submitter’s Name Submitter’s Email
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Accepting New Patients Update Form
29375509 • 6-20
If you are having diculty submitting the form once completed, please send using one
of the following methods:
• Email:
– Click on “File” at the top of your screen
– Click on “Save As”
– Save the completed form on your computer
– Attach the completed form to an email and send to providerforms@bcbsnd.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave. S.
Fargo, ND 58121
