Fillable Ambulance Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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Ambulance Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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The Ambulance Recredentialing Application (Blue Cross Blue Shield of North Dakota) form is 2 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 51 other fields

Country of origin: US
File type: PDF

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29380172 • 2-21
Instructions: All providers are required to attest to the appropriate corresponding program criteria attached. Recredentialing is
conducted every three years and unless you are notied, participation will remain eective 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 diculty 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 certicate 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 dierent from physical address)
Street Street
City State Zip City State Zip
Oce Phone # Oce Fax # Billing Phone # Billing Fax #
Oce Sta Foreign Languages
Speak
Read
Write
N/A
Business Oce Contact Name Business Oce Email Address
NPI Number Date Business Opened Name and Title of Chief Administrator
Type of Facility/Ownership
Government (Federal, State, County, City)
Private Non-Prot
Private For Prot
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
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29380172 • 2-21
Liability Insurance (Required)
Attached is a copy of the liability certicate or letter from insurance provider
Yes
Release and Attestation
The undersigned is authorized to act on behalf of the institution/facility (Entity), and certies that all information submitted
on this application and all attachments hereto are correct, true and complete to the best of my knowledge.
The Entity consents to complete disclosure of and authorization to make available to Blue Cross Blue Shield of North Dakota
(BCBSND), its aliates or any of their agents, all relevant information pertaining to and deemed necessary and appropriate
in the investigation and processing of this application, including but not limited to, information obtained through a third party
such as an insurance company, licensing authority, accrediting agency or governmental agency.
The Entity releases and discharges BCBSND, its aliates and their representatives, credentials committees, administrators,
governing bodies, agents, employees and all other persons or entities supplying information to them, from liability or claims
of any kind or character in any way arising out of inquiries or disclosures made in good faith
in connection with this application.
The Entity agrees to update this application while it is being processed should there be any change in the information provided
regarding the Entity that could aect the application or its outcome. A photocopy of this document shall be as eective as the original.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
Please double check that the application is complete.
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Ambulance Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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