Fillable Coverage Change Request Form (Blue Cross Blue Shield of North Dakota)

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Coverage Change Request Form (Blue Cross Blue Shield of North Dakota)

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The Coverage Change Request Form (Blue Cross Blue Shield of North Dakota) form is 1 page long and contains:

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  • 3 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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29379820 • 8-19Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Coverage Change Request Form
Use this form only if you are:
1. Currently enrolled in one of the employers health plans; and
2. Keeping the SAME individuals covered (no change in dependent coverage). If you are adding
or removing dependents, a group application is required; and
3. Electing to change to the selected health plan below.
Return completed forms by:
• Mail: Blue Cross Blue Shield of North Dakota
Attn: Enrollment Department
4510 13th Avenue S.
Fargo, ND 58121
Coverage Change – Option 1
I Elect
Health Group Number
Network Name (if applicable)
OR
Coverage Change – Option 2
I Elect
Health Group Number
Network Name (if applicable)
OR
Coverage Change – Option 3
I Elect
Health Group Number
Network Name (if applicable)
Employer Information
Employer Name Phone Number
Employee Information
First Name MI Last Name
Unique Member Identifier (UMI) Requested Eective Date
Work Phone Number Home Phone Number
Signature Date
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Coverage Change Request Form (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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