Fillable Medical Records Submission Form (Blue Cross Blue Shield of North Dakota)

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Medical Records Submission Form (Blue Cross Blue Shield of North Dakota)

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Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Medical Records Submission Form
To submit medical records for paper or electronic claims led to Blue Cross Blue Shield of North Dakota (BCBSND), please
complete this form and submit with all pertinent medical records.
Please return completed forms by:
• Mail: BCBSND
4510 13th Ave S
Fargo, ND 58121
• Fax: (701) 277-2132
Provider Information
Provider Name
NPI
Member Information
Last Name First Name
Date of Birth (mm/dd/yyyy) Member ID Number
Claim Number(s)
Date(s) of Service (mm/dd/yyyy)
29379860 • 10-19
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Medical Records Submission Form (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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