Fillable Medication-Assisted Treatment Facility Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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Medication-Assisted Treatment Facility Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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The Medication-Assisted Treatment Facility Recredentialing Application (Blue Cross Blue Shield of North Dakota) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

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Page 1 of 2
29379626 • 6-20
Medication-Assisted Treatment Facility
Recredentialing Application
Instructions: All providers should complete Sections A and B. Complete the portions of the sections that apply to your
organization by attesting to the program requirements outlined in this form. 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.
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
Street
City State Zip
Billing/Mailing Address (If dierent from physical address)
Street
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 Neither
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 a copy of malpractice insurance face sheet? Yes No
Opioid Treatment Program Current License / Certication (Attach a current copy licenses and certicates)
State
Current State License,
Certication Number
Original Issue Date
(MM/DD/YYYY)
Expiration Date
(MM/DD/YYYY)
State License
(Nonprovisional)
SAMHSA Opioid Treatment
Program Certication
DEA
Medicaid
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Page 2 of 2
29379626 • 6-20
Malpractice/Liability Insurance (Continued)
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)
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’
- 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
Please double check that the application is complete.
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Medication-Assisted Treatment Facility Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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