Forms / Resources
NDFB Member Medical Claim Submission Form
Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.
Use this form to request reimbursement for covered medications purchased at retail cost.
This document is intended to help you quickly compare coverage benefits and is a summary of in-network benefits only.
Request for Reconsideration of Declined Coverage
This form is for you to complete when submitting a request for reconsideration of declined coverage for you or any dependents.
Request for Reconsideration of Rate
This form is for you to complete when submitting a request for reconsideration of your rate for coverage.
Request for Reconsideration of Benefit Exclusion Rider
This form is for you to complete when submitting a request for reconsideration of a benefit exclusion rider that has been placed on you or any dependents. Please use one form per rider being reviewed.
Request for Reconsideration of Tobacco Rate
This form is for you to complete when submitting a request for reconsideration of tobacco rate for coverage.
Medical request form (age 0-2 months)
This is a request form for any type of medical records that need to be requested for newborns through two months of age.
Medical Request Form (age 3-25 months)
This is a request form for any type of medical records that need to be requested for children 3-25 months old.
Medical request form (age 40 and older)
This is a request form for any type of medical records that need to be requested for adults aged 40 or older.
If you need to change your bank information for your monthly premium payment, please complete this form, attach a voided check and mail both to North Dakota Farm Bureau Health Plans.
This form allows an employer to let NDFB Health Plans know an employee/client of NDFB Health Plans no longer works for them and the client will take over the health plan payment.
Alternative Plan Selection Form
This form allows you to make changes to your current coverage.
Please complete this form if cancelling your coverage with North Dakota Farm Bureau Health Plans.
Personal Representative Designation
Your completion of this form allows you to designate someone as your personal representative on your North Dakota Farm Bureau Health Plans coverage.
This resource explains the grievance procedure used by North Dakota Farm Bureau Health Plans.
Use this form if you would like to file a grievance, after you've read the grievance procedure.