Forms and Documentation

About Interactive PDFs

You can add your information directly on the form to complete it, however, completed forms cannot be saved.

You can save a blank version of the form. We recommend printing a copy for BCBSNC and one for your records.

Additional Information

Use these forms and documents to manage your benefits from BCBSNC. See Additional Information for more about these forms.

Claims Forms

For Benefits Received in North Carolina or Out-of-Network in the U.S.
Note: most providers in the BCBSNC network will file a claim on your behalf.

PDF Medical, Vision and Medical Supplies
PDF Formulario de reclamación para afiliados
PDF Prescription Drugs
PDF Formulario de reclamacion por las recetas de drogas (Spanish)
PDF Pediatric Dental claim form
PDF Dental Blue — Individual/Senior Plan
PDF Dental Blue — Group Plan
PDF Dental Blue Select — Group Voluntary Plan

For Benefits Received Outside the U.S.

PDF International Claim Form (English)
PDF Sample Complete Claim Form
PDF Reclamo Internacional (Spanish)

For benefits received on a cruise ship while outside the country; please submit the domestic claim forms.

Appeals Forms

PDF Claim Appeal Form
PDF Member Appeal Representation Authorization Form

These appeals forms are unintended for appealing underwriting decisions. If you wish to appeal an underwriting decision, try one of the following:

  • Check your underwriting decision letter for appeal instructions.
  • Contact your local agent.
  • Call us at 1-888-922-3140.

Benefits Documentation

PDF Continuity of Care Form — allows members and their dependents to continue receiving care from a provider who is no longer in the Blue Cross NC network.

Order Certification of Health Insurance Coverage — for terminated (ended) policies

PDF BCBSNC Member Authorization Form — authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
PDF Solicitud de autorización del afiliado (Spanish)
PDF Student Leave of Absence Certification Form — certifies a dependent child has lost their student status at a postsecondary educational institution due to a leave of absence caused by a serious illness or injury. You may be able to continue their coverage. A physician must complete this form.

Blue 20/20 Benefit Booklets

PDF 2017 Blue 20/20 - Exam Plus Booklet Erisa
PDF 2017 Blue 20/20 - Exam Plus Booklet Non-Erisa
PDF 2017 Blue 20/20 - Lens and Frame Only Erisa
PDF 2017 Blue 20/20 - Lens and Frame Only Non-Erisa
PDF 2016 Blue 20/20 - Exam Only Benefit Plan
PDF 2016 Blue 20/20 - Exam Plus Benefit Plan
PDF 2016 Blue 20/20 - Lens and Frames Only Benefit Plan

To view PDF documents you need Adobe Acrobat Reader, provided free from