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

Member Information

*Required Fields

Please enter a valid Date.

Residential Street Address

Mailing Address

Submitter Information

*Required Fields

Submitter Address

Provider Information

*Required Fields

Facility Address

Service Information

Date must be today's date or a future 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.