Members

1.  Download and install Acrobat Reader.
2.  Select the form you would like to complete.
3.  Use Acrobat Reader and your printer to print the form.
4.  Fill out the printed form.
5.  See the form for specific mailing information.

• Member Claim Form Usually providers of health care bill Blue Cross directly for services to you and your enrolled dependents. However, if you have to submit a claim for medical services you must complete this form.  Please see page 2 of this form for instructions on how to complete this form and submit it to Blue Cross.
  
  

• Individual Enrollment Application

  Complete this form for any of the following reasons.
  
  
  • To add a dependent to your contract whose age is over 60 days from birth.
    
    
  • If you are enrolled in a CaliforniaCare (HMO) or Basic Hospital (PPO) plan and want to change to a different plan.
    
    
  • Give to a friend or relative would like to enroll in a Blue Cross Plan.
    
    
  If the dependent you want to add to your contract is a newborn (i.e. under 60 days old), you can add him/her to your contract by contacting us at the customer service number listed on your ID card, or by sending us a written request. Please include the policies primary member ID number, full name of newborn, date of birth and gender. You may fax this request to Membership Services at (805) 480-8813.
  
  
• Exceptions to Standard Enrollment The signature dates on the Individual Enrollment Application or Change of Coverage Application are valid for 30 days.  If, when your application is being processed, the signature date(s) exceeds 30 days, you will be required to complete and submit this form. This usually happens when you sign the application long before you mail it to Blue Cross.