Helpful forms

Choosing your plan (if you’re not a BCBSRI member yet)

The easiest way to enroll in our health and dental plans is using our simple shopping tool online. But we understand that sometimes you need to use paper, so you can download these forms:

2019

  • Enroll in a 2019 medical and/or dental plan
  • Enroll in a 2019 dental direct plan
  • List additional dependents on your application

2018

  • Enroll in a 2018 medical and/or dental plan
  • Enroll in a 2018 dental direct plan
  • List additional dependents on your application – English

Making changes (if you already have a BCBSRI plan)

Note: some changes require a qualifying event before the change can be made.

2019

  • Change your 2019 medical and dental plan
  • Cancel your electronic payments
  • Add Dependent Form (for plans purchased directly from BCBSRI)
    Use this form if you already have a policy with BCBSRI and need to add a new dependent (e.g. newborn, spouse, etc.).

2018

  • Change your 2018 medical and dental plan
  • Cancel your electronic payments
  • Add Dependent Form (for plans purchased directly from BCBSRI)
    Use this form if you already have a policy with BCBSRI and need to add a new dependent (e.g. newborn, spouse, etc.).

Add other health insurance

Do you or anyone else covered by your Blue Cross health plan have another health plan? If so, we can help you make the most of your benefits—and possibly save you money! Simply complete this form and mail to:

Attn: OCL Department (A) - 00119
Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, RI 02903-2699

Coupon for expecting Blue Cross Dental members

Studies have shown that it’s important for pregnant women to receive regular dental care—that is why pregnant Blue Cross Dental members are eligible for one extra dental cleaning per year with this Dental Coupon.

Other forms you might need

  • International Claim Form
    Claim form used when services are rendered outside of United States. Follow the steps below to access the claim form:
    1. Accept the terms and conditions
    2. Enter the 3 character prefix from the member's ID
    3. Click on Claim Forms and choose the form preferred
    *For more information and to confirm your coverage, please call Customer Service
  • Member Reimbursement Donor Egg and Sperm
    Complete and submit this form to request reimbursement.
  • Member Reimbursement Oral Enteral Food Products Form
    Complete and submit this form to request reimbursement.

You want the right plan. We can help you choose.

Call (401) 459-5550 or just come by:
Warwick location
Warwick
Cowesett Corners
300 Quaker Lane
East Providence location
East Providence
Highland Commons
71 Highland Avenue
Lincoln location
Lincoln
Lincoln Mall Shopping Center
622 George Washington Hwy
Visit Your Blue Store
Or send our sales team a message

Thank you for sending us your information.

We will be in touch soon to help you choose a plan that's right for you.