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Please complete every section of the attached form. The following list may be used as a reference to assist you with the application.
Recredentialing is conducted every three years and unless you are notied, participation will remain eective with no gaps.
Malpractice/Liability Insurance: Attach the malpractice insurance certicate or face sheet and evidence on letterhead
(e.g. roster, letter, or fax) which clearly states that the provider, facility, or institution is covered by the insurance policy.
The face sheet will also need to include the name of insurance company, from and through dates, policy number, and
If you have any questions, please call 800-756-2749 or send an email to email@example.com.
Optical Supplier Information (Please complete a separate application for each location)
Name of Facility Federal TIN
Medicare Certication # or Medicare Participation # Taxonomy Code
Physical Street Address (Street, City, State, Zip) Billing/Mailing Address (Street, City, State, Zip)
(If dierent from physical address)
Zip City State Zip
Oce Phone # Oce Fax # Billing Telephone # Billing Fax #
Oce Sta Foreign Languages
Business Oce Contact Name Business Oce Email Address
NPI Number Date Business Opened Name and Title of Chief Administrator
Type of Facility/Ownership
Government (Federal, State, County, City)
Private For Prot
Group Practice Assoc.
Attach copy of malpractice certicate or face sheet.
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Optical Supplier Check List
and Credentialing Application