Most Common Forms

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

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

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

Direct Pay Plans (On and Off Exchange)
Authorize BCBSND to deduct your monthly health care premium payment or change your bank account information.

Appeal Form
Request to review an adverse decision.

Apply or change coverage
(non-employer plans)

Get a Quote and Apply
Open enrollment begins November 1, 2022 - January 15, 2023.
If you have a qualifying life event, like a new baby or marriage, you can get a quote and apply today.
If you purchase health insurance through your employer, please contact your plan administrator for application forms.

Change to 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.

Prefer to download and mail your application? Application for new coverage

Automatic payment

Bank Account Change & Automatic Payment Withdrawal
Authorize BCBSND to deduct your monthly health care premium payment from your bank account. 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
Complete online Authorized Representative Form

Authorization to Release Information
Complete online Authorization to Release Information Form (i.e., life insurance company request or child immunization records).

Prefer to download and mail your form?
Authorized Representative
Authorization to Release Information

Claims

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.

Blue Cross Blue Shield Global Core International Claim Form
Use for international claims from providers outside of the United States.

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.

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 nonparticipating 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 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).

Forms to be completed by your provider

Blue Cross Blue Shield of North Dakota has additional forms to be completed by your provider

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