Most common forms

Employee Change Form

Submit form to cancel coverage or change employee name or address.

Member Claim Form

Assist an employee in filing a claim for medical services.

Billing and payments

Electronic Funds Transfer (EFT) Authorization Agreement

Complete bank information and attach a copy of a cancelled or voided check to verify account and routing/transit numbers. Payment withdrawals from your bank account will be completed on the 1st of the month. Billing schedule is subject to change due to holidays and weekends.

Fully Insured Billing Guide

Guide to your invoice and billing package.

Eligibility and renewals

2021 Medical Loss Ratio (MLR) Form

Submit the MLR form, as required by the Affordable Care Act (ACA).

Employee Change Form

Submit this form to cancel an employee's coverage, change an employee's address or update an employee's name. You may also be able to complete this change online faster and easier within the Employer Portal.

Health Affiliation and OOA Waiver

If you offer a health plan that requires the selection of a specific network, use this form to:

• Choose a network
• Change network at renewal, or one other time in the year
• Put a waiver on a covered family member who may reside outside the network service area

Fully Insured Group RxDC Reporting Form 

Submit this form to your BCBSND Account Representative for the 2022 RxDC calendar year reporting.

• Metallic or Non-Metallic plans to complete Section A. Metallic plan(s) to complete Section B.
• Groups with more than one plan must submit one form for each plan. 

2022 RxDC Reporting Form