Common Member Forms
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Contact Member Services
Please return completed forms to: 4510 13th Ave S Fargo ND 58121 or Fax to: 701-282-1888
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.
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.)
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.
For college-attending dependents required to take a medical leave of absence from school.
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. Members on a plan with prefix YQE need to contact Member Services at 1-800-342-4718 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.
File a claim for Vision Services.
Request an Independent 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).
Request a medical necessity predetermination review.