Blue Cross & Blue Shield of Rhode Island Application

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 2-4 on the Group Dependent Addendum if it appears in your column.
* Your spouse is not considered a "dependent" in this chart.
If you are applying for Medical coverage, or Medical and Dental coverage, use these forms:
With up to 2 dependents *
With 3 or more dependents *
If you are applying for Dental coverage, use these forms:
With up to 4 dependents *
With 5 or more dependents *

NOTE: If you are only applying for dental coverage, skip to Step 4: Send My Application.

Step 2: Direct Pay Medical Underwriting Addendum

This form is required only if you are applying for medical coverage and meet either of the following two conditions

-  You are applying for a preferred rate.

Blue Cross offers a preferred rate for those who complete a health status questionnaire and are then approved. A preferred rate reduces the cost of your monthly premium.

- You don't have a Certificate of Creditable Coverage and the open enrollment period (May 15 - June 15) is closed for Blue Cross direct plans.

 A Certificate of Creditable Coverage is also called a HIPAA Notice, which you can obtain by requesting it from your last medical insurer. A Certificate of Creditable Coverage shows your last insurer's name, the dates you were covered, and your name as the policy holder.

  If neither of these conditions apply to you, skip to step 3: AccessBlue Application.

Step 2 Directions:

  • You will need health information for everyone you wish to cover on your medical plan
  • Click on the form link.
  • Fill the information into the addendum form using your computer.
  • Print the application form

Direct Pay Medical Underwriting Addendum

NOTE: If you are only applying for dental coverage, skip to Step 4: Send Your Application

Step 3: AccessBlue Application

This form is required only if you are applying for the AccessBlue program

Blue Cross offers a program called AccessBlue, where a portion of your monthly bill for health coverage may be paid by Blue Cross. The amount you'll receive depends on your income and whether you enroll in an individual or family plan.The amount will be indicated on your bill. In order to apply you will need to submit hard copies of your financial information, including:

* Federal Income Tax Form 1040, 1040A, or 1040EZ, including all schedules filed

OR

* Statements of Social Security benefits (if applicable)
* All W-2 forms
* All 1099 forms

If you do not wish to apply for the AccessBlue program, skip to Step 4: Send Your Application.

Step 3 Directions:

  • You will need tax information for everyone in your household.
  • Click on the form link.
  • Fill the information into the application form using your computer.
  • Print the application form.

AccessBlue Application

Step 4: 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.

 

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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