Claims forms
For benefits received on a cruise ship, please submit the domestic claim 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.
Need help submitting a claim? Please visit our Member Knowledge Center for detailed instructions.
Appeals forms
For more information on submitting an appeal, please visit our Member Knowledge Center.
Coverage forms
Continuity of Care Form (PDF) – allows members and their dependents to continue receiving care from a provider who is no longer in the Blue Cross NC network.
Blue Cross NC Member Authorization Form (PDF) – authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
Student Leave of Absence Certification Form (PDF) – 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.
Solicitud de autorización del afiliado (Spanish) (PDF)
Order Certification of Health Insurance Coverage Form – for terminated (ended) policies
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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