Regence BlueShield     Evolve Plus     Evolve Core   HSA Plans     Evolve HSA 50     Evolve HSA 80     Evolve HSA 100   Plan Rates   Apply Now!   Provider Directory   Waiting Period     & Exclusions   FAQ's   LifeWise of WA   Group Health   HSA Plans   Individual Dental   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application   US Citizens   Foreign Nationals   Long Term		(Available to Washington State Residents Only) Regence BlueShield Individual Medical Application Process and Forms There are now 2 ways to enroll in the Regence Individual Plans: Online Enrollment To Enroll On-Line – Click Here or Print and Mail Enrollment Forms Fill out the Application (one per family) Click here to download the Regence BlueShield Individual/Family Enrollment Application. Print the application and fill it out completely. Fill out the Questionnaire (one for each person to be covered) Click here to 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 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 BlueShield. If applying for an HSA plan: Fill out the HSA Application & Forms (one per family) Click here to enroll on-line (fastest way to set up an account) or Click here to print the HSA Application Packet and mail it in. Note: To be eligible for Regence BlueShield coverage you must reside in the Washington State Regence BlueShield service area at least 30 days prior to application (see map). Must reside in Regence BlueShield Service Area (see map) Must reside in the service area 30 days prior to application and continue to live in the Regence BlueShield service area for six months out of the year. A photocopy of a valid Washington state driver's license, identification card, or current utility bill with name and address may be requested as proof of residency. Do not Send a Payment Please do not send a rate payment with your application. You will receive a statement from Regence BlueShield upon acceptance of your application. If you would like to set up auto-pay via Electronic Funds Transfer, please click here to complete the Regence Preauthorized Bill Payment form. You may submit the Preauthorization Bill Payment form with your application. Send all Enrollment Materials to: Regence Blue Shield P.O. Box 1107 1602 21st Ave Lewiston, ID 83501 Please note: Upon approval, you will be eligible for an effective date of the first of the month following the date the completed application was received in the Regence Blue Shield office, unless otherwise indicated. Incomplete applications may cause delays in your effective date. E-mail us for more information and a free quote or CALL TOLL FREE 1-800-875-4490 (in the U.S.) or 1-253-854-0199 (outside the U.S.) Fax: 1-253-896-9411 Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424 Serving all of Washington at 800-875-4490, Seattle at 206-682-1628, Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291. Copyright© 1998-2010, Maddock & Associates  |  Privacy Statement Problems viewing this page? Contact the webmaster.