Medicare Supplement Application

Thank you for your interest in submitting a Medicare supplement application with BCBSND.

To Apply:
Click on the link below to complete the application. You may complete it while it is open on your computer desktop and then print it. Or you may print it first and then complete it by hand.
Also complete and submit the following Health Information Form if you are applying outside open enrollment or the guaranteed issue period. 
The Medicare supplement application requires you to acknowledge you have received the Outline of Coverage and Guide to Health Insurance for People with Medicare. Those publications are available immediately below.
After you complete the application, sign it and submit it to BCBSND by one of the following methods:
  • Mail it to:
    Blue Cross Blue Shield of North Dakota
    Attn: Medicare Supplement Customer Service
    4510 13th Avenue South
    Fargo, ND 58103-9986
  • Fax it to:
    Attn: Medicare Supplement Customer Service
  • Scan it and Send it as an Email Attachment to: