Request for Cancellation
29377566 8-19
Name: Please Print __________________________________________________________________________
Eective Date Requested: ____________________________________________________________________
Please cancel my:
¨
Blue Cross Blue Shield of North Dakota Bill Account/UMI: _______________
Reason for Cancellation:
Cancellation requests must reach the Blue Cross Blue Shield Oce before the first of the month of the
requested cancellation date, and must be signed by the subscriber.
Signature: _________________________________________________________________________________
Phone: ________________________________________ Date: ______________________________________
Mail completed form to Blue Cross Blue Shield of North Dakota, 4510 13th Ave S, Fargo, ND 58121
click to sign
signature
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4510 13
th
Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
29376608 1-19
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the
following disclosure:
Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of
race, color, national origin, age, disability, gender identity, sexual orientation or sex.
Blue Cross Blue Shield of North Dakota:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, please call Member Services at 1-844-363-8457 (toll-free) or through the
North Dakota Relay at 1-800-366-6888 or 711.
If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex, you can file a grievance with:
Civil Rights Coordinator
4510 13th Ave S
Fargo, ND 58121
701-297-1638 or North Dakota Relay at 800-366-6888 or 711
701-282-1804 (fax)
CivilRightsCoordinator@bcbsnd.com (email) (Communication by unencrypted email presents a risk.)
You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged
discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 1-844-363-8457.
If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800-368-1019 or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Español (Spanish)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-844-363-8457 (TTY: 1-800-366-6888 oder 711).
中文 (Chinese)
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-844-363-8457TTY1-800-366-6888
711)。
Oroomiffa (Oromo)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
1-844-363-8457 (TTY: 1-800-366-6888 ykn 711).
Tiếng Vit (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-844-363-8457 (TTY: 1-800-366-6888 hoc 711).
Ikirundi (Bantu Kirundi)
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu.
Woterefona 1-844-363-8457 (TTY: 1-800-366-6888 canke 711).
اﻟر (Arabic)
ﻣﻠﺣ وظ ﺔ: إذا ﻧ ت دث اذر ا ، ن دﻣﺎ ت ا ﻣ ﺳدة ا ﻠﻐو وار ك ﻟﻣ ﺟن. ا ل رم
844-363-8457-1 م ھ ف ا م و ا م :
1-800-366-6888 أو 711(.
Kiswahili (Swahili)
KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo.
Piga simu 1-844-363-8457 (TTY: 1-800-366-6888 au 711).
Русский (Russian)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-844-363-8457 (телетайп: 1-800-366-6888 или 711).
日本語
(Japanese)
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-844-363-8457
TTY: 1-800-366-6888 または 711)まで、お電話にてご連絡ください。
नेपाल& (Nepali)
!यान %दन
होस: तपाइ/ले नेपाल2 बो4न
5छ भन तपाइ/को 9नि;त भाषा सहायता सेवाह> 9नःश
4 >पमा उपलCध फोन गन
Hहोस
1-844-363-8457 (%ट%टवाइ: 1-800-366-6888 वा 711)
Français (French)
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-844-363-8457 (ATS : 1-800-366-6888 ou 711).
한국어 (Korean)
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 있습니다. 1-844-363-8457
(TTY: 1-800-366-6888
또는 711)번으 전화해 주십시.
Tagalog (Tagalog Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Norsk (Norwegian)
MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-844-363-8457
(TTY: 1-800-366-6888 eller 711).
Diné Bizaad (Navajo)
Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee ákáánída’áwo’dę
́
ę
́
’, t’áá jiik’eh, éí ná hólǫ
́
,
kojį’ hódíílnih 1-844-363-8457 (TTY: 1-800-366-6888 éí doodagó 711.)