Medicaid Expansion ER Admission Notification

Please complete the following form for any Medicaid Expansion Member who visited the ER and was discharged, NOT admitted to the hospital.

Member

* Required fields

Member First Name

Member Last Name

Member Date of Birth

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Member ID Number

Member Phone Number

Submitter

Provider First Name

Provider Last Name

Provider NPI

Facility

Submitter First Name

Submitter Last Name

Facility Contact Phone Number

Reason for the ER Visit

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121