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Regence BlueShield of Idaho Logo
Idaho State For Employers and Group Benefits Administrators
Health Plan Information
Use the Right Forms
For ActivateSM, InnovaSM, EngageSM and HSA Heathplan 2.0SM products, use these new forms only. Do not use the forms listed below for these products.

Important Note: 2012 Product Changes
Effective January 1, 2012, some Regence products will be discontinued or closed to groups sized 2-99. Please see the Product Transition Page for more information.

Forms Descriptions
QUOTE REQUEST FORMS
Group Proposal Request Form (PDF) (2 to 99 eligible employees) This form is required for Regence BlueShield of Idaho to provide your business with a quote for health insurance coverage.
APPLICATION & ENROLLMENT FORMS
Small Group Application (2 to 50 eligible employees)
 Use this form to add a new employee to your group plan. Note: A cover sheet is no longer needed.
Large Group Application for Enrollment (PDF) (Experience-rated or ASC) Use this form to complete information for employees of groups that are experience-rated or ASC groups.
Application for Enrollment (PDF) (51-99 employees) Use this form to complete information for employees of groups with 51 to 99 employees.
Eligibility Adjustments Form (PDF) Use this form to record eligibility adjustments reflected on your group's premium billing invoice.
Membership Maintenance Form (PDF) Use this form when an employee experiences a life change such as adding/deleting dependents, name change or changes at open enrollment.
Employee Waiver of Coverage Agreement (PDF) Use this form to specify that employees are waiving their opportunity for health insurance coverage with Regence BlueShield of Idaho.
Employee Certification (PDF) Use this form to certify that employees meet the required hourly guidelines to be eligible for health insurance with your company.

Special Beginnings® Enrollment

Eligible employees who want to join the Special Beginnings Maternity Management program must complete an enrollment questionnaire. It can be submitted online, or by mail or fax to:

Special Beginnings
Regence BlueShield of Idaho
PO Box 1106 Mail Station LA1W
Lewiston, ID 83501
FAX: (208) 798-2092
Retiree Insurance Benefits Request Form (PDF) Please complete this form when planning to retire but still requesting insurance coverage from your group.
Willamette Dental Enrollment and Change of Information (PDF) Use this form when applying for and/or changing information regarding group dental coverage through Willamette Dental of Idaho, Inc.
Adding a Newborn to Your Policy (PDF) Use this form to add a newborn to your policy.
Affidavit of Qualifying Incapacitated Dependent Eligibility (Fillable PDF) Use this form to certify that an eligible dependent child is incapacitated due to medical disability, developmental disability or mental disorder.
AUTHORIZATION FORMS

Authorization for Use and Disclosure of Protected Health Information (PDF)

Authorization for Regence BlueShield of Idaho and/or a member's health care providers to disclose health information to a designated party for a specific purpose.

Statement of Accidental Death Form (PDF) If your group has the Accidental Death benefit, use this form upon the accidental death of a contract holder or covered dependent.
PRESCRIPTION MEDICATION MAIL-ORDER FORMS
Prescription mail-order forms are available on the RegenceRx Web site.
FORMS REQUESTING ADDITIONAL INFORMATION
Multiple Coverage Inquiry Form (PDF) Use this form when Regence needs to verify a member's other insurance coverage.
Accident Report (PDF) Use this form to verify accident information and third-party liability.
REQUEST SUPPLIES
Employer's Supply Request Form (PDF) Please complete this form when you need materials from Regence BlueShield of Idaho.

 
Regence BlueShield of Idaho. All rights reserved. Regence BlueShield of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association.
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