Apply for coverage from
Regence BlueCross BlueShield of OR
Index | Regence
BlueCross BlueShield Enrollment Form
• Standard Health Questionnaire for use with coverage that begins on or after July 21, 2011.
Application Process and Forms
To apply for any of the Regence BlueCross BlueShield
of Oregon individual medical plans, please complete
the following steps:
- Fill out the Application (one per
family)
Download the Regence BlueCross
BlueShield of Oregon Individual/Family Enrollment
Application from the link above. Print the application and fill it out
completely.
- Fill out the Questionnaire (one
for each person to be covered)
Download the Standard Health
Questionnaire for Washington State. Print and complete
the questionnaire for each person
to be covered on the plan. Please refer to Completing
the Health Questionnaire to determine
if this applies.
- Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a
Washington state resident.
A photocopy of one of the following must accompany
your application to prove residency:
- Valid Washington State Driver's License or Identification
Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including
address
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage & HIPPA Eligibility
for more information. Please note, if you do not have
your Certificate of Creditable Coverage at the time
of application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by Regence BlueCross BlueShield
of Oregon.
- Do not Send a Payment
Please do not send a rate payment with your application.
You will receive a statement from Regence BlueCross
BlueShield of Oregon upon acceptance of your application.
- Send all Enrollment Materials to:
CDA Insurance Services
P.O. Box 26540
Eugene, OR 97402
Please note: Regence BlueCross BlueShield
of Oregon requires all COMPLETED enrollment
materials to be postmarked to their office on or before
the 20th of the month. Incomplete enrollments may cause
delays in the effective date of your coverage. Please
refer to the checklist on the application to avoid delays.
For Example: If you wanted your medical
insurance coverage to begin on April 1, you would need
to send all of the required, completed enrollment material
to Regence BlueCross BlueShield of Oregon postmarked on
or before March 20.
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