Forms

• Employer Verification of Insurance Coverage (SFN 53621)
• Authorization for Premium Deduction (SFN 50134)
• TFFR Payroll Deduction Authorization (SFN 19182)
• Verification of Alternate Retirement Plan (SFN 53863)
• Retiree Group Health Insurance Application (SFN 16277)
• Retiree Health Insurance with Medicare Application (SFN-59562)
• Request to Cancel Retiree Health Insurance Coverage (SFN 58269)
• Medicare Prescription Drug Plan Enrollment Form
• Authorization for Use or Disclosure of Protected Health Information (SFN-58769)
• Health Care Information Release Accounting Form (56768)
• Participant's Authorization to Disclose Protected Health Information (SFN-58770)
• Request to Access Protected Health Information (SFN-58771)
• Participant Request for Confidential Communications (SFN-58772)
• Request for Restrictions On Use and/or Disclosure of Protected Health Information (SFN-58773)
• Group PDP Disenrollment Form
• Retiree Continuation of Group Health Insurance Coverage (COBRA) (SFN 53799)

Publications

• Guide to Your Explanation of Benefits

Links

• Network Provider Directory
• Blue Cross/Blue Shield of ND - (Home Page) (Member Services)

Other Information

• Is Case Management for You?