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29380794 • 2-21
Read all instructions carefully prior to submitting your application.
Tips to avoid delays: Complete only this application. Do not use another insurance plan’s application. If handwritten, use a blue
or black ink ball-point pen only. Do not use a pencil. Print legibly. Complete all sections that are applicable to you. Include all
additional information requested.
If you have any questions, please call 800-756-2749 or send an email to
Facility/Agency Type (Place a check next to ALL correct classications)
Ambulatory Surgery Center
Diabetes Prevention Program
Dialysis/Kidney Center
Free Standing Radiology/Portable X-Ray Supplier
General Hospital (Short Term)
General Hospital (Long Term)
Hearing Aid Supplier
Home Health Agency
Laboratory (Independent or Hospital-Based)
Rehabilitation Facility
Skilled Nursing Facility
Swing Bed
Urgent Care
Other (Description):
Institution or Facility Information (Please complete a separate application for each practicing location)
Name of Facility Federal TIN
NPI Eective Date of Group
Taxonomy Code
Display in Directory
Yes No
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
Patient Appointment Phone # Oce Fax # Billing Phone # Billing Fax #
Oce Sta Foreign Languages
Business Oce Contact Name Business Oce Email Address
Is the Facility Certied as a National Disaster Medical System (NDMS)?
Name and Title of Chief Administrator Total Licensed Bed Capacity
Facility Accepts (Check all that apply)
Credit Card
Debit Card
Trauma Level
I – All Complex Injuries
II – Severe Trauma
III – Common Trauma w/o specialized care
IV – Routine Care
V – Routine Care – May not be 24/7
0 – No Trauma Care
Credentialing Application
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29380794 • 2-21
Current License/Certicate (Attach a current copy of all licenses and certicates that apply)
Issued By
Current State License
Or Certication #
Original Issue Date Expiration Date
Medicare Certication #
The Joint Commission
(Commission On Accreditation
of Rehabilitation Facilities)
(American Association
for Accreditation of Ambulatory
Surgery Facilities)
(Accreditation Assoc. for
Ambulatory Health Care, Inc.)
Malpractice/Liability Insurance
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 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)
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’
- Save the completed form on your computer
- Attach the completed form to an email and send to
Fax: 701-282-1910
Mail: 4510 13th Ave S
Fargo, ND 58121
click to sign
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