NDIIS User Registration
BCBSND

When requesting access to the North Dakota Immunization Information System (NDIIS), it is important that your provider site has a current, fully executed Provider Site Agreement on file with the ND Department of Health Division of Immunizations.

Please complete the form below in its entirety. Once the form has been submitted, NDIIS Support Services will contact your Site Administrator for approval. The Site Administrator must reply back to the Support team within 5 business days in order for them to proceed with your access request. Once they receive approval from the Site Administrator, Support Services will complete the set up of your access and will contact you directly with your login information.

If you are experiencing issues with the form, please contact NDIIS Support Services at 1-800-544-8467 | Email: NDIISSupport@bcbsnd.com

Registration Form
Error: {{vm.countMissingFields(RegInfoForm.$error)}} missing or invalid field{{vm.countMissingFields(RegInfoForm.$error) > 1 ? "s" : ""}}.

Site Demographics

Primary Contact

The Primary Contact is the person authorizing user(s) access to NDIIS


User Information

Click on "Add User" below to get started. You must add at least one user.

You must enter at least one user

{{user.firstName + " " + user.lastName}}
{{vm.submissionErrorMessage}}
User Information

If you would like to register more than one user, click Save then click "Add User" again.

Error: {{vm.countMissingFields(UserInfoForm.$error)}} missing or invalid field{{vm.countMissingFields(UserInfoForm.$error) > 1 ? "s" : ""}}.
Track vaccine information needed to administer and verify timely immunizations.

Identify your state immunization provider number(s):


Comments

NDIIS Registration Submitted
Create another NDIIS Registration

View Submitted Registration

Click here to viewhide your submitted registration.

Submit Date: {{vm.submitDate | date:'medium'}}
Site Demographics
Name: {{vm.thorRegistration.siteName}}
Address Line 1 : {{vm.thorRegistration.address1}}
Address Line 2: {{vm.thorRegistration.address2}}
City: {{vm.thorRegistration.city}}
State: {{vm.thorRegistration.state}}
Zip Code: {{vm.thorRegistration.zipCode}}
Primary Contact Information
Name: {{vm.thorRegistration.primaryContactFirstName + " " + vm.thorRegistration.primaryContactLastName}}
Phone: ({{vm.thorRegistration.primaryContactPhone.substring(0,3)}}) {{vm.thorRegistration.primaryContactPhone.substring(3,6)}}-{{vm.thorRegistration.primaryContactPhone.substring(6,10)}}   Ext: {{vm.thorRegistration.primaryContactExtension}}
Email: {{vm.thorRegistration.primaryContactEmail}}
User Information
Name: {{user.firstName + " " + user.lastName}}
Phone: ({{user.phoneNumber.substring(0,3)}}) {{user.phoneNumber.substring(3,6)}}-{{user.phoneNumber.substring(6,10)}}   Ext: {{user.extension}}
Email: {{user.email}}
Electronic Services Requested:
ND Immunization Information System
{{$index+1}}. Provider Name: {{prov.name}}
    ND State Immunization Number: {{prov.immunizationNumber}}
    Security Type: {{prov.securityType}}
Comments: {{user.comments}}