Advance Member Notice
Completion of this form acknowledges that the member is fully responsible for all charges associated with the professional
or institutional procedure/item/service requested below because the procedure/item/service may not be medically necessary
and/or is not a covered benet. This notice is not required for the member to receive medically appropriate and necessary
covered services.
Procedure/Item/Service (Estimated) Billed Charge
For The Patient
I acknowledge that I am voluntarily signing this statement, and that it is not being signed under duress or after the services
have already been provided. I understand that by signing this form, I will be fully responsible for the total billed charge(s)
for any procedure/item/service listed above that is denied as non-covered by Blue Cross Blue Shield of North Dakota and
will pay the provider as charged. I also understand that it is my choice to have the services provided at a future date and
time by this provider.
Patient Name
Benet Plan Number
Patient Signature Date
For The Provider
As a participating Blue Cross Blue Shield of North Dakota provider, I certify that I have informed the above patient regarding
the Advance Member Notice. I acknowledge that BCBSND medical policy, BCBSND Participation Agreement provisions,
and any other policies promulgated by BCBSND, including any resulting decisions on nancial responsibility, supersede
this Advance Member Notice.
Provider Name
Provider Signature Date
4510 13th Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
29379424 • 7-20
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