TEST Out-of-State Non-Participating Health Care Provider Waiver Form

This form is for BCBSND members who need non-emergency care from a provider outside of North Dakota who is not in-network.

Find a Doctor to see if you can get care from participating (in-network) providers to lower your cost.

Submit this waiver if:

You are getting certain mental health or substance use services, like intensive outpatient or partial hospitalization programs.
You need specialized services such as durable medical equipment, lab testing, radiology, or wound grafting.
You’re seeking non-emergency services from a provider who is not part of the Blue Cross Blue Shield network.

Important things to know:

Even with an approved waiver, your costs will be based on what BCBSND considers reasonable for the service. You are responsible for any charges that are higher than that amount.
If you do not get a waiver for services that require one, those costs may not be covered.

Information you will need

Member information including member ID number

Provider information including the type of care they give

The Facility name, address, and National Provider Identifier (NPI) – you can ask your provider for this.

Service information such as reason for your appointment, the date of service/care, and the service you are requesting a waiver for.

* Indicates required fields

Who is this waiver for? Myself

Spouse

Dependent age 11 or younger

Dependent age 12 or older

Other

Member Information

*Required Fields

Member First Name

Member Last Name

Member Date of Birth

Please enter a valid Date.

Member ID

Member Contact Phone Number

Residential Street Address

Address Line 1

Address Line 2

City

ZIP Code

Mailing Address

Same as Physical Address? Yes

Submitter Information

*Required Fields

Submitter First Name

Submitter MI

Submitter Last Name

Submitter Contact Phone Number

Submitter Address

Address Line 1

Address Line 2

City

ZIP Code

Provider Information

*Required Fields

Provider First Name (optional)

Provider Last Name (optional)

Facility Name

Facility Address

Address Line 1

Address Line 2

City

ZIP Code

Service Information

Reason for appointment

Date must be today's date or a future date.

Have you had an opportunity to verify whether you are consulting with a participating or in-state provider? Yes

Review

*Required Fields

Who is this waiver for? : Edit

Member Information

Member First Name : Edit

MI : Edit

Member Last Name : Edit

Member Date of Birth : Edit

Member ID : Edit

Member Contact Phone Number : Edit

Address Line 1 : Edit

Address Line 2 : Edit

City : Edit

State : Edit

ZIP Code : Edit

Mailing Address same as Physical Address? : Edit

Submitter Information

Submitter First Name : Edit

Submitter MI : Edit

Submitter Last Name : Edit

Submitter Contact Phone Number : Edit

Address Line 1 : Edit

Address Line 2 : Edit

City : Edit

State : Edit

ZIP Code : Edit

Provider Information

Provider First Name (optional) : Edit

Provider Last Name (optional) : Edit

Facility Name : Edit

Facility NPI (optional) : Edit

Address Line 1 : Edit

Address Line 2 : Edit

City : Edit

State : Edit

ZIP Code : Edit

Service type : Edit

Reason for appointment : Edit

Date of Service/Care : Edit

Submitter Signature

I accept *

By checking this box, I understand I am creating an electronic signature that carries the same legal obligations as a written signature and am agreeing to all of the terms and conditions set forth within this application, including the Notification and Authorization.