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Blue Cross NC Home Providers Forms & documents Member appeal representation authorization form Providers Member appeal representation authorization

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has always been committed to protecting our Members’ health information, and have implemented policies and procedures to safeguard their information.

Authorizing a member appeal representative

Members can grant authority to a third party (such as a provider or other representative) to file an appeal on their behalf. Follow these steps to submit the Member Appeal Representation Authorization Form.

Member Appeal Representation Authorization Form (PDF)

Member Appeal Representation Authorization Form in Spanish (PDF)
How to complete the form

See below for some helpful tips when filling out the Member Appeal Representation Authorization Form:

  • Make sure the following fields are completed: Patient Name, Member ID Number, and Patient Date of Birth.
  • Complete the "Claim Number(s) or Service Description" field with the authorization claim number (if applicable), the service being appealed, or the issue being appealed.
  • Replace "Person/Entity Authorized to Act on Your Behalf" with the name of the person that you are allowing to appeal on your behalf, and add that person's phone number to "Representative Phone Number."
  • Complete the "Provider Name" field with the name of the provider who will be performing / who has performed the service.
  • If your request is for a service that has not yet been performed, you can leave the "Date(s) of Service" field blank or enter "Future."
  • Sign and date the form.
  • Mail the completed form and appeal request to:
    Blue Cross NC, PO Box 30055, Durham, NC 27702-3005.

Please read the Notice of Privacy Practices that explains in more detail our practices concerning Members’ protected health information.