Common Forms

Many forms have a convenient online option, as well as a downloadable paper (PDF) option which can be printed, then mailed or faxed.

Medical - Member Submitted Claims

File a claim for medical services.
Member Submitted Medical Claim
Member Submitted Medical Claim (Paper)

Pharmacy - Member Submitted Claims
Complete and mail with all pharmacy receipts to Prime Therapeutics.
Member Submitted Pharmacy Claim (Paper)

File a claim for pharmacy services if you have prescription coverage through your medical plan.
Major Medical Pharmacy Claim (Paper)

International travel claims
BCBS Global® Core International Claim (Paper)

Authorizations

Authorized Representative Form

This form lets you name one or more people or organizations to receive your health information on your behalf. It also covers situations where a minor (ages 12–17) has the right under applicable law to control whether a parent or guardian can access their health information.

Authorized Representative (Paper)

Authorization to Release Information Form (ADHI)

Authorization to Release Information (Paper)

Automatic Payments

Authorize BCBSND to deduct your monthly health care premium payment from your bank account. (Your payment may take up to 3 business days to post to your account.)

Automatic Payments Form (Paper)
Learn more about bill pay

Appeals

Appeal Form
Appeal Form (Paper)

Vida Appeal Form (Paper) (for members who have been medically excluded from Vida Health)

Additional Forms

  • Coverage Options

    Coverage Options

    If you purchase health insurance through your employer, please contact your plan administrator for application forms.


    Applying for new coverage
    Get a Quote and Apply
    Application for new coverage - 2026 plans (Paper)


    Change existing coverage
    If you purchase insurance individually (not through an employer) and need to make a change, please call us at 800‑280‑2583. If you get your insurance through work, please contact your HR Department.


    Cancel existing coverage
    Request for Cancellation (Paper)


    NOTE: Members on a plan with prefix YEP should contact the Federal Marketplace (FFM) at 800‑318‑2596 to cancel coverage.

  • Demographic Change Form

    Demographic Change Form

    Update demographic information such as name, address, date of birth and social security number.


    Demographic Change Form

    Demographic Change Form (Paper)

  • Medical Review Forms

    Medical Review Forms

    Continuity of Care Form (Paper)
    Request a review for continuing coverage for specific medical conditions from a nonparticipating or out-of-network provider.


    Member External Review Form – Non-Grandfathered (Paper)
    Request an independent external review.
    This form can only be used for members on non-grandfathered plans. Please contact Member Services at 844-363-8457 to check if your plan has the option for an external review.


    Member External Review Form – Grandfathered (Paper)
    Request an independent external review.
    This form can only be used for members on grandfathered plans. Please contact Member Services at 844-363-8457 to check if your plan has the option for an external review.


    Member Pharmacy Coverage Exception Form – External Review (Paper)
    Request an independent external review for a noncovered 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).

  • Report Medical Dual Coverage

    Report Medical Dual Coverage

    Use this form to report additional medical coverage to BCBSND for Coordination of Benefits (COB).


    Report Medical Dual Coverage

  • Request Member ID Card

    Request Member ID Card

    Your digital member ID card is available to view or print in the Member Portal. If you prefer to have a replacement card(s) mailed to the subscriber's address on file, send the request by submitting your Member ID below. You will find your Member ID by logging into the portal or on your current ID card. If you don't have a portal account setup call member services, 844-363-8457 for assistance.


    Request Member ID Card

  • Out-of-State Non-Participating Health Care Provider Waiver Form

    Out-of-State Non-Participating Health Care Provider Waiver Form

    This form is for Blue Cross Blue Shield of North Dakota (BCBSND) Marketplace (Affordable Care Act) members who need non-urgent, nonemergency care from a provider outside of North Dakota who is non-participating with BCBSND.


    Out-of-State Non-Participating Health Care Provider Waiver Form

  • Other Eligibility and Enrollment Forms

    Other Eligibility and Enrollment Forms

    Application for Dependent Disability (Paper)
    For dependent children incapable of self-support because of mental or physical disabilities, request coverage beyond the standard age.


    Authorization for Enrollment or Eligibility (Paper)
    Authorize release of health information for purposes of enrolling in a health insurance plan.


    Authorization for Release of Medical Information to Primary Applicant (Paper)
    Authorize BCBSND to disclose to the primary applicant medical information that was used in making insurability decisions.


    Coverage Change Request Form (Paper)
    Use to change health plans if currently enrolled in an employer plan and there is no change in covered individuals on plan.


    Out-of-Area Waiver Form (Paper)
    For dependents living outside of their network provider due to divorce or school attendance. Also use to change your network affiliation. In most cases, changes can be submitted one month prior to your group anniversary.