Common Member Forms
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Contact Member Services
Please return completed forms to: 4510 13th Ave S Fargo ND 58121
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.
Authorized BCBSND to deduct your monthly health care premium payment from your bank account. If your UMI starts with YQE and YQB, 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.)
Authorize others for ongoing access to your health information.
Authorize limited access to your health information (i.e., life insurance company request).
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.
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. NOTE: Members on a plan with prefix YEP should contact the Federal Marketplace (FFM) at 1-800-318-2596 to cancel their coverage and are unable to submit the cancellation form.
File claims from providers outside the U.S.
Member Submitted Claim Forms
File a claim for Medical Services.
File a claim for Pharmacy Services. Please note, as of January 1, 2019, the process for submitting pharmacy claims has changed; the form must be filled out in its entirety and pharmacy receipts must be provided for claims to be processed. If you have Major Medical coverage, use the form below.
File a claim for Pharmacy Services if you have prescription coverage through Major Medical.
Appeal Form Request to review an adverse decision with supporting documentation.
Request a review for continuing coverage for specific medical conditions from a non-participating or out of network provider.
Request an Independent External Review. This form can only be used for members on Non-Grandfathered plans. Please contact Member Services at 1-844-363-8457 to check if your plan has the option for an external review.
Request an Independent External Review for a Non-Covered Medication. This form is to be used for members who purchased coverage directly through an insurance company or through an insurance exchange (for example, a BlueCare, BlueDirect or BlueEssential plan).
Forms to be completed by your provider
Blue Cross Blue Shield of North Dakota has additional forms to be completed by your provider. For a listing of those forms, please click here.