ENROLLMENT FORMS

All enrollment forms should be submitted to Christie Colón in Human Resources

Don't forget to provide the dependent eligibility documentation if you're adding a dependent.

These forms are fillable and signable. Once you've opened the form, please click "Download" to download the signable version.

MEMBERSHIP CHANGE FORM

Making changes to your current medical plan (like adding or deleting a dependent)? Please fill out the Membership Change form.

Use this form to enroll for the first time and follow these instructions:

Blue Shield PPO or HSA – you must write HSA or PPO in the top margin on the form
Blue Shield HMO – you must select a doctor when enrolling in this plan and include the doctor's IPA & PCP information on the enrollment form:
- IPA is the Medical Network/Group Name
- PCP is the Primary Care Physician #

Here’s how to search on Blue Shield's website for the IPA and PCP information and to select a Blue Shield HMO doctor in your area:

Search Blue Shield Doctors in your area
Click on “Primary Care Physician”
Type in your location
Select Specialty, like “Family Practice”, “Internal Medicine”, etc.
Next to the doctor's name you'll see the medical network they belong to - you'll need to enter that in the "IPA" field on the enrollment form.
Click on the doctor's name and you'll find the Primary Care Physician ID (PCP) that you'll need to enter on the enrollment form.

Use this form to enroll for the first time and follow these instructions:

* Be sure to check "HMO" or "Deductible plan" in Section A on enrollment form

If you work more than 90% and want to waive your health insurance, please fill out these three forms:

Dental Form – fill out this dental enrollment form to enroll for the first time or when making changes to your plan

Make changes to your life insurance beneficiaries
Life insurance enrollment forms are only available directly from Human Resources and are not posted here.