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Public Health Unit Check List
and Credentialing Application
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 firstname.lastname@example.org.
Public Health Unit Information (Please complete a separate application for each location)
Name of Facility Federal TIN
Physical Street Address (Street, City, State, Zip)
City State Zip
Billing/Mailing Address (Street, City, State, Zip)
(If dierent from physical address)
City State Zip
Oce Phone # Oce Fax # Billing Phone # Billing Fax #
Oce Sta Foreign Languages Speak Read Write N/A
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 face sheet.
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association