Our Member Services Representatives are unavailable Thursday, November 26, and Friday, November 27, due to the holiday. (Medium)

Most common forms

Authorized Representative

Give permission to others for ongoing access to your health information.

Direct Pay Plans for (On and Off Exchange)

Authorize BCBSND to deduct your monthly health care premium payment or change your bank account information.

Medical Services – Member Submitted Claim

File a claim for medical services.

Pharmacy Services – Member Submitted Claim

Complete and mail with all pharmacy receipts to Prime Therapeutics.

Appeals

Request to review an adverse decision.

Can't find the form you need?

Contact Member Services

Please send completed forms as indicated on each form. Or, if in question, you may send via U.S. mail to:  

4510 13th Avenue South

Fargo, ND 58121

Individual health care coverage

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

Existing Coverage  
Make changes to existing health care coverage.

Get a quote and apply online now

Application for New Coverage  
During special enrollment, you'll use this application to apply for health coverage.


Automatic payment

Bank Account Change & Automatic Payment Withdrawal
Authorize BCBSND to deduct your monthly health care premium payment or change your bank account information. If you have a direct pay plan, please use this form to sign up for electronic payments (ACH). This is not applicable if you purchase insurance through your employer.


Authorizations

Authorized Representative
Authorize others for ongoing access to your health information.

Authorization to Release Information
Authorize limited access to your health information (i.e., life insurance company request or child immunization records).


Eligibility

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

Out of Area Waiver Form
For dependents living 50+ miles from 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.


Enrollment

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

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

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

Demographic Change Form
Update demographic information such as name, address and date of birth.

Request for Cancellation
Cancel a health insurance benefit plan.
NOTE: Members on a plan with prefix YEP should contact the Federal Marketplace (FFM) at 800-318-2596 to cancel coverage.


International claims

Blue Cross Blue Shield Global Core International Claim Form
File claims from providers outside the U.S.


Member Submitted Claim Forms

Medical Services - Member Submitted Claim Form
File a claim for medical services.

Pharmacy Services - Member Submitted Claim Form
File a claim for pharmacy services. The form must be completed in its entirety and pharmacy receipts must be provided for claims to be processed through Prime Therapeutics. If you get pharmacy coverage through your medical plan, use the form below.

Pharmacy Services - Major Medical Member Submitted Claim Form
File a claim for pharmacy services if you have prescription coverage through your medical plan.


Medical review

Appeal Form
Request to review an adverse decision with supporting documentation.

Continuity of Care Form
Request a review for continuing coverage for specific medical conditions from a non-participating or out of network provider.

Member External Review Form – Non-Grandfathered
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
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
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.