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:

2023

• Enroll in a 2023 medical and/or dental plan
• Enroll in a 2023 dental direct plan
• List additional dependents on your application

Making changes (if you already have a BCBSRI plan)

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

2023

• Change your 2023 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 (for example, newborn, spouse, etc.).

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.
• Confidential Communication Form
• Doula Services Claims Submission Form
  Complete and submit this form to request reimbursement.
• Paxlovid Consultation With a Pharmacist Reimbursement Form
  If you consulted with a pharmacist about a prescription for Paxlovid and they charged you, you can submit for reimbursement by completing this form.