Page 1 of 2
29380790 • 6-20
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 notied, participation will remain eective with no gaps.
Facility Information
Malpractice/Liability Insurance: Attach the malpractice insurance certicate 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
occurrence/aggregate amounts.
Signed Attestation
If you have any questions, please call 800-756-2749 or send an email to
Public Health Unit Information (Please complete a separate application for each location)
Name of Facility Federal TIN
Taxonomy Code
Physical Street Address (Street, City, State, Zip)
City State Zip
Billing/Mailing Address (Street, City, State, Zip)
(If dierent from physical address)
City State Zip
Oce Phone # Oce Fax # Billing Phone # Billing Fax #
Oce Sta Foreign Languages Speak Read Write N/A
Business Oce Contact Name Business Oce Email Address
NPI Number Date Business Opened Name and Title of Chief Administrator
Type of Facility/Ownership
Government (Federal, State, County, City)
Private Non-Prot
Private For Prot
Organizational Structure
Public Agency
Group Practice Assoc.
Single Owner
Professional Corporation
Malpractice/Liability Insurance
Attach copy of malpractice face sheet.
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Page 2 of 2
29380790 • 6-20
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
click to edit