Blue Cross & Blue Shield of Rhode Island Application

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Application download

Thank you for choosing Blue Cross for your medical and/or dental insurance needs.

Applying for individual or family health insurance is an easy step-by-step process. Simply follow the steps below to find and complete the forms you will need to apply, and mail/fax us your application.

In order to view, edit, and print these forms, you will need Adobe Acrobat, which you can download on their website.

Step 1: The Application Form

Everyone needs at least one of the application forms below. Follow the directions to see what you need.

Step 1 Directions:
1) Find the column of fields that identifies with your application for coverage.
2) Click on a form link in that column.
3) Fill the information into the application form using your computer.
4) Print the application form.
5) Repeat steps on the Group Dependent Addendum if it appears in your column.
* Your spouse is not considered a "dependent" in this chart.
2016 Forms
If you are applying for Medical coverage, or Medical and Dental coverage, use these forms:
If you are applying for Dental coverage, use these forms:

Step 2: Send Your Application

You can send us your application either of the following ways:
1) Mail all the documents of your application to:

Blue Cross & Blue Shield of Rhode Island
Attn: Individual Sales Department
500 Exchange Street
Providence, RI 02903-2699

2) Fax all the documents of your application to:

Blue Cross & Blue Shield of Rhode Island
Attn: Individual Sales Department
(401) 459-5378

Thank you for choosing Blue Cross & Blue Shield of Rhode Island to be your insurance carrier. We look forward to reviewing your application. If you have any questions you need answered by a Blue Cross representative, feel free to contact us at the numbers below.

 

 

Support for your current plan
Local: 401-351-BLUE (2583)
Toll-free: 800-505-BLUE (2583)
TTY: 888-252-5051
Monday - Friday, 8am - 8pm
Assistance with purchasing a plan
Local: 401-459-5000
Toll-free: 800-505-BLUE (2583)
TTY: 888-252-5051
Monday - Saturday, 8am - 8pm