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Instructions: All providers are required to attest to the appropriate corresponding program criteria attached. Recredentialing is
conducted every three years and unless you are notied, participation will remain eective with no gaps.
If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.
Submit instructions:
If you are having diculty submitting the form once completed, please send using one of the following methods:
• Email (Please follow these steps):
- Click on ‘File’ at the top of your screen
- Click on ‘Save As’ and 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
Liability insurance: All providers are required to submit with this form a copy of liability certicate or letter from
insurance provider.
Ambulance Facility Information (Please complete a separate application for each location)
Name of Ambulance Facility Federal TIN Taxonomy Code
Physical Street Address (Street, City, State, Zip) Billing/Mailing Address (Street, City, State, Zip)
(If dierent from physical address)
Street Street
City State Zip City State Zip
Oce Phone # Oce Fax # Billing Phone # Billing Fax #
Oce Sta Foreign Languages
Speak
Read
Write
N/A
Business Oce Contact Name Business Oce Email Address
NPI Number Date Business Opened Name and Title of Chief Administrator
Type of Facility/Ownership
Government (Federal, State, County, City)
Private Non-Prot
Private For Prot
Other:
Organizational Structure
Corporation
Partnership
Single Owner
Public Agency
Group Practice Assoc.
Professional Corporation
Does Ambulance Facility Accept (Check all that apply)
Credit Card
Debit Card
Neither
Current License(s)
State Current License Number Original Issue Date Expiration Date
Ambulance Recredentialing Application