TEST - MedeWorks Provider Organization Request Form

BlueAlliance and BlueAlliance Care + programs, Blue Cross Blue Shield of North Dakota (BCBSND) provides access to the MedeWorks Provider Dashboard.

To ensure that no Protected Health Information (PHI) is distributed to unauthorized parties, access to BCBSND tools is governed by a strict access policy. Each BlueAlliance and BlueAlliance Care + provider organization is required to have an Authorized Access Approver identified.

Responsibilities of the Authorized Access Approver include:

  • Reviewing requests from individuals from your organization who desire access to the MedeWorks dashboard to monitor performance in the BlueAlliance and BlueAlliance Care + programs. 
  • Signing off on the BlueAlliance & BlueAlliance Care + Dashboard MedeWorks User Access Request Form authorizing BCBSND to provide the requester access, either with PHI information or without it, to your organization’s BlueAlliance and/or BlueAlliance Care + SharePoint sites and Dashboards appropriate for their documented role.
  • Maintaining and notifying BCBSND of any changes in the relationship between your organization and the users who have been granted access to your organization’s dashboard (i.e., termed employment/relationship). User’s access can be changed or removed by using the same MedeWorks User Access Request Form.

For questions about this form, email BlueAlliance@bcbsnd.com

User Information

*Required Fields

Approver Signature

*Required Fields

By checking this box, I acknowledge the responsibility of approving users access to the MedeWorks dashboard within my organization and I understand I am creating an electronic signature that carries the same legal obligations as a written signature. I agree to all the terms and conditions set forth within this request form.