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Current License/Certicate (Attach a current copy of all licenses and certicates that apply)
Current State License
Or Certication #
Original Issue Date Expiration Date
Medicare Certication #
The Joint Commission
(Commission On Accreditation
of Rehabilitation Facilities)
for Accreditation of Ambulatory
(Accreditation Assoc. for
Ambulatory Health Care, Inc.)
Attach a copy of malpractice insurance face sheet.
Release and Attestation
The undersigned is authorized to act on behalf of the institution/facility (Entity), and certies 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 aliates 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 aliates 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 aect the application or its outcome. A photocopy of this document shall be as eective as the original.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
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’
- Save the completed form on your computer
- Attach the completed form to an email and send to email@example.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave S
Fargo, ND 58121
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