Member forms
Select the type of form you need
Claim forms
Medical, vision, and medical supplies claims forms
Most members can submit medical claims online in the Blue Cross NC member portal. You can also print forms and submit by mail or fax:
Medical, Vision, and Medical Supplies Claim Form (PDF)
Formulario de reclamación para afiliados (Spanish) (PDF)
- Mail: Blue Cross and Blue Shield of North Carolina
PO Box 35
Durham, NC 27702-3055 - Fax: 866-990-1385
Note: Use the member claim form if you needed health services on a cruise ship.
Prescription drug claims forms
If you need to submit a prescription drug claim, you can choose the form you need:
Prescription Drug Claims Form (PDF)
Formulario de reclamación por medicamentos recetados (Spanish) (PDF)
- Mail: Prime Therapeutics (Commercial) Mail route BCBSNC
PO Box 25136
Lehigh Valley, PA 18002-5136
Claim form for services rendered outside the U.S.
You may need a claim form for services received or rendered outside of the U.S. For benefits received on a cruise ship, please submit the domestic claim forms.
International Claim Form (PDF)
- Mail: Service Center
PO Box 2048
Southeastern, PA 19399 - Email: claims@bcbsglobalcore.com
- Online: BCBS Global Core
Reclamo Internacional (Spanish) (PDF)
- Mail: Bluecard Worldwide Service Center
PO Box 261630
Miami, FL 33126 - Email: claims@bluecardworldwide.com
Dental claims forms
You may need to submit a dental claim. You can choose the American Dental Association® (ADA) claim forms based on your type of Blue Cross NC dental plan:
Member travel benefit claims forms
The claim form only applies if your health plan offers a travel benefit. You must sign the form to verify that you traveled out-of-state for a medical service covered and approved by your health plan.
Member Travel Benefit Form (PDF)
Member Travel Benefit Reimbursement for Transplant Services Form (PDF)
- Mail: Blue Cross and Blue Shield of North Carolina
PO Box 35
Durham, NC 27702-3055 - Fax: 866-990-1385
Appeals forms
Member appeal form
If you need to file a medical appeal, you can choose the form you need:
Formulario de apelación de reclamaciones (Spanish) (PDF)
- Mail: Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 30055
Durham, NC 27702-3055
Member appeal representation authorization forms
You can submit the Member Appeal Representation Authorization Form to give a trusted representative the ability to file an appeal on your behalf. Add your representative's name as "Person/Entity Authorized to Act on Your Behalf." If your request is for a service that has not yet been performed, leave the "Date(s) of Service" field blank.
Member Appeal Representation Authorization Form (PDF)
Formulario de autorización de representación ante apelaciones del afiliado (Spanish) (PDF)
- Mail: Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 30055
Durham, NC 27702-3055
Dental appeals and grievances forms
If you need to file a dental appeal or grievance, you can choose the form you need:
Dental Appeals and Grievances (PDF)
Dental Apelaciones y Quejas (Spanish) (PDF)
- Mail: Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 2100
Winston-Salem, NC 27102-2100 - Fax: 336-714-0224
Coverage forms
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.
- Mail: Blue Cross and Blue Shield of North Carolina
Care Management
PO Box 2291
Durham, NC 27702-2291
Member authorization form
You have the right to give a caregiver, loved one, or trusted person access to your protected health information (PHI). In order to do so, you need to give Blue Cross NC written authorization.
Parents or guardians of dependent children over 18 (or between the ages of 14–18 for certain diagnoses) will also need their dependent to provide authorization before we can share their PHI with you.
You can submit online through your Blue Cross NC member portal.
You can also print, complete, and mail the form.
Authorization Request Form (PDF)
Authorization Request Form (Spanish) (PDF)
- Mail: Commercial Operations / IDC
Blue Cross and Blue Shield of North Carolina
PO Box 2291
Durham, NC 27702-2291
Student leave of absence certification forms
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.
Student Leave of Absence Certification Form (PDF)
- Mail: Blue Cross and Blue Shield of North Carolina
Manager Enrollment and Billing Operations
PO Box 2291
Durham, NC 27702-2291
Certification of health insurance coverage form
You can request a certification for terminated policies from Blue Cross NC for up to 24 months following the last effective date of your policy.
If your policy is still active, and you need a Certification of Creditable Coverage document, please call the Customer Service number on your Blue Cross NC member ID card.
To submit an online request, you must be a member of the referenced Blue Cross NC health plan, or a group benefits administrator authorized to make requests on the member’s behalf.
After we receive your request, you'll receive your proof of coverage certification through regular mail within 10 days.
Tax documents
Accessing your 1095-A
Form 1095-A is prepared by the Health Insurance Marketplace and can only be found at Healthcare.gov. You will not have a 1095-A form if you have a catastrophic health plan from the marketplace.
You can access your 1095-A by:
- Logging in to your HealthCare.gov account.
- Clicking on the "Go to my Applications and Coverage" link at the top of the page.
- Selecting the previous tax year application under "Your Existing Applications." For example, select the 2024 application during the 2025 calendar year.
- Clicking on "Tax Forms" from the menu on the left of the page.
- Downloading all 1095-A forms shown on the screen.
Accessing your 1095-B
The 1095-B form was created to show proof of health insurance for the individual mandate, which no longer exists. Consult your tax advisor for questions, as this form may not be needed.
Blue Cross NC stopped mailing out this form, but you can download a copy through the member portal. If you don't access it through the member portal, please allow up to 30 days for us to send you a copy. Note: Some restrictions apply and paper copies must be mailed in certain states.
You can get a copy of form 1095-B in several different ways:
Member portal
If you would still like a copy of Form 1095-B, you can get a copy from the member portal. Go to the Documents and Forms page from your account menu to find it.
By phone
Call us to request a copy at 800-326-0052.
By writing
Send a request in writing to Customer Service at:
Blue Cross NC
ATTN: IRC6055
PO Box 2291
Durham, NC 27702
By email
Request a copy by emailing TaxFormRequest@bcbsnc.com.
Please be aware that email communication can be intercepted in transmission or misdirected. If you are uncomfortable with sending your health information via unsecured email, please consider communicating by using one of the other methods on this page.
Please include your name (as it appears on your member ID card), email address, member ID number, date of birth, and your home mailing address.
Note: By sending an email to this address, I am affirmatively consenting to receive my 1095-B Form via email and understand by doing so that I will not receive a paper copy of Form 1095-B unless I specifically request one. As a convenience to me, I hereby request and authorize Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to provide me with this form electronically. I understand that it is my responsibility to ensure Blue Cross NC has my up-to-date email address and that it is in fact correct and accurate. I further understand that I am solely responsible for ensuring my email address is functioning properly at all times and that Blue Cross NC has no liability for errors in transmission of the electronic Form 1095-B other than addressing the electronic form to the email address I provided. I acknowledge and agree that the date of receipt of my electronic Form 1095-B shall be the date and time on which I requested it, regardless of the date and time I actually receive and/or review this form.