Common Member Forms

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Application for Individual Health Care Coverage
If you purchase health insurance through your employer, please contact your plan administrator for application forms.

Make changes to existing health care coverage.
 
 
Automatic Payment
Authorize BCBSND to deduct your monthly health care premium payment from your bank account. If your Benefit Plan Number starts with YQE please use this form to sign up for ACH. (Not applicable if you purchase insurance through your employer.)
 
Authorize BCBSND to deduct your monthly health care premium payment from your bank account. If your Benefit Plan Number starts with anything other than YQE please use this form to sign up for ACH. (Not applicable if you purchase insurance through your employer.)
 
Use to notify BCBSND of any changes. (Not applicable if you purchase insurance through your employer.)
 
Authorizations
Authorize others for ongoing access to your health information.
 
Authorize limited access to your health information (i.e., life insurance company request).
 
Eligibility
For dependent children incapable of self-support because of mental or physical disabilities, request coverage beyond the standard age.
 
For dependents living 50+ miles from their network provider due to divorce or school attendance. Also used to change your network affiliation. In most cases, changes can be submitted one month prior to your group anniversary.
 
For college-attending dependents required to take a medical leave of absence from school.
 
Enrollment
Authorize release of health information for purposes of enrolling in a health insurance plan.
 
Authorize BCBSND to disclose to the primary applicant medical information that was used in making insurability decisions. 
 
Cancel a health insurance benefit plan.
 
International Claims
File claims from providers outside the U.S.
 
Member Submitted Claim Forms
File a claim for Medical Services.
 
File a claim for Pharmacy Services.
 
File a claim for Vision Services.
 
Medical Review
Request an Independent External Review.