Forms

The following forms will help you manage your BCBSRI plan:
AccessBlue Application

Use this form to apply for AccessBlue, a program we offer to make healthcare more affordable for qualifying individuals and families by helping them pay their monthly health plan premiums.

Dental Direct Plan Option Change Form

Existing members may use this form to request a dental plan change.

Electronic Payment Option Cancellation Form

Use this form if you would like to stop having your monthly premium payment automatically deducted from your bank account.

Electronic Payment Option Form

You can choose to have your monthly premium payment deducted automatically from your checking or savings account through the Electronic Payment Option Plan. Instructions for enrolling in this payment plan are included on the form.  Please note: The Electronic Payment Option is only available to members purchasing health and/or dental coverage directly with BCBSRI.  If you enrolled through HealthSource RI, please call 1-855-651-7873 for information about payment options. 

Plans for Individuals and Families Health Plan Option Change Form

Use this form if you are a current member and would like to change your 2014 health coverage during Open Enrollment (through March 31, 2014).

Health and Dental Plan Application for Individuals and Families
If you are not a member, but would like to apply for one of our plans for individuals and families please choose from these forms.