Forms

The following forms will help you manage your BCBSRI plan:
BlueCHiP for Healthy Options Member Application

BlueCHiP for Healthy Options Member Application

Electronic Enrollment Authorization Form

Electronic Enrollment Authorization Form

Electronic Payment Option Form
Electronic Payment Form to have your group's monthly premium payment electronically deducted from your group's checking account. Please note: The Electronic Payment Option is only available to groups purchasing health and/or dental coverage directly with BCBSRI.  If you purchased coverage through HealthSource RI, please call 1-855-651-7873 for information about payment options. 
Employer Support Inquiry

Please use this form to submit an inquiry to the Employer Support Team.

Group Activity Report (GAR)

Group Activity Report

Group Activity Report (GAR) Instruction Sheet

Group Activity Report (GAR) Instruction Sheet

Group Dependent Addendum

Group Dependent Addendum

Group Enrollment Checklist

Group Enrollment Checklist

Group Plan65 Member Application

Group Plan65 Member Application

Request for Amendment to the Sales Agreement

Request for Amendment to the Sales Agreement

Small Group Member Application

Small Group Member Application

Small Group Sales Agreement

Small Group Sales Agreement