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
- Member Appeals
- BlueCard (claims for services received outside NC)
- Provide Details of Other Coverage
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.
Medical, Vision and Medical Supplies
Prescription Drugs
Formulario de reclamacion por las recetas de drogas (Spanish)
Dental Blue — Individual Plan
Dental Blue — Group Plan
Dental Blue Select — Group Voluntary Plan
For Benefits Received Outside the U.S.
International Claim Form (English)
Sample Complete Claim Form
Reclamo Internacional (Spanish)
For benefits received on a cruise ship while outside the country; please submit the domestic claim forms.
Appeals Forms
Claim Appeal Form
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
Order Certification of Health Insurance Coverage — for terminated (ended) policies
BCBSNC Member Authorization Form — authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
Solicitud de autorización del afiliado (Spanish)
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.
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