POD 29380534 • 4-20
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Demographic Change Form
Return completed forms by:
Attn: Enrollment Department
4510 13th Ave. S.
Fargo, ND 58121
Member Information
Member Name (please print) Unique Member Identifier
Request for Updating Member Information
Updating Member Information
Name Change
Eective Date (MM/DD/YYYY)
Address Change
Eective Date (MM/DD/YYYY)
Date of Birth Change
Eective Date (MM/DD/YYYY)
Name Change
First Name Middle Name Last Name
Address Change
If temporary change please check NOTE: Member must update address when they return
Is this change to Physical home address Mailing address (e.g. PO BOX)
Address Line 1
Address Line 2
City State Zip
Date of Birth Change
Birth Date (MM/DD/YYYY)
Member Contact Information
Contact Information
Name (please print) Phone Number
Authorized Signature Date
click to sign
click to edit