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29378667 • 6-20
Instructions: All providers should complete Sections A and B. Complete the portions the sections that apply to your organization
by attesting to the program requirements outlined in this form.
Section A: Program Type (Place a check next to ALL correct classications)
Opioid Treatment Program
Oce-Based Opioid Treatment
Section B: Provider Information
Facility Information (Please complete a separate application for each practicing location)
Name of Facility Federal TIN
NPI Eective Date of Group
Physical Street Address Billing/Mailing Address (If dierent from physical address)
Street Street
City State
Zip City State Zip
Patient Appointment Phone # Oce Fax # Billing Telephone # Billing Fax #
Business Oce Contact Name and Phone # Business Oce Contact Email
Name and Title of Chief Administrator
Facility accepts (Check all that apply):
Credit Card
Debit Card
Malpractice/Liability Insurance
Attach the malpractice insurance face sheet and evidence (e.g. roster, letter, fax) that clearly states the name
of provider being credentialed and covered under your insurance policy. The face sheet must also contain the name
of insurance company, from and through dates, policy number and occurrence/aggregate coverage amounts.
Did you attach copy of malpractice insurance face sheet?
Opioid Treatment Program Current License / Certication (Attach a current copy licenses and certicates)
Current State License,
Certication Number
Original Issue Date
Expiration Date
State License
SAMHSA Opioid Treatment
Program Certication
Medication-Assisted Treatment Facility
Credentialing Application
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
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29378667 • 6-20
Release and Attestation
The undersigned is authorized to act on behalf of the institution (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.
If you are having diculty submitting the form once completed, please send using one
of the following methods:
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
click to edit