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

This form is for Blue Cross Blue Shield of North Dakota (BCBSND) Marketplace (Affordable Care Act) members who need non-urgent, non-emergency care from a provider outside of North Dakota who is non-participating.

Find a Doctor to see if you can get care from participating (non-urgent & non-emergency) 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. 
  • Even with an approved waiver, your costs will be based on your BCBSND coverage as outlined in your enrolled plan. You are responsible for any charged above the plan allowance.
  • If you do not get a waiver for services that require one, those costs may not be covered.
  • Some services may require prior authorization.

* Indicates required fields

Member Information

*Required Fields

Please enter a valid Date.

Residential Street Address

Mailing Address

Please note, the determination of your request will be mailed to the mailing address if different from the residental address.

Submitter Information

*Required Fields

Submitter Address

Provider Information

*Required Fields

Facility Address

Service Information

Date can not be more than 120 days before or after today's date.

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

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.