Instructions
- Please click on the application and fill it out online.
- Print a copy of your completed form and don't forget to sign it before submitting.
- (Optional) Print out the Surepay form and complete by hand.
Hints
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Enrolling yourself and your spouse? Both of you will need to fill out a separate enrollment form.
- Select the plan you want.
- Decide if you want your premium deducted from your personal checking, savings or money market account (you will need to fill out the Surepay form listed below).
- Answer all questions so we can process your application without delay.
- The 2009 Enrollment Form is for coverage effective in 2009.
- The 2010 Enrollment Form is for coverage effective January 1, 2010 or later.
PDF (132k) 2009 Enrollment Form
PDF (80k) 2010 Enrollment Form
PDF (35k) Optional: 2009 Surepay Form
PDF (44k) Optional: 2010 Surepay Form
Where to mail enrollment and Surepay forms
Regence BlueCross BlueShield of Oregon
Medicare Membership Accounting MS:S5B
P.O. Box 12625
Salem, Oregon 97309-0625
Where to fax enrollment and Surepay forms
Please fax to this number: 1-888-335-2988.
If you fax your forms to us, you do not need to mail them as well.
Where to call for more information
Please call us at 1-888-REGENCE (1-888-734-3623) for answers to questions about applying for coverage. Our hours are 8 to 5 p.m., Monday through Friday, Pacific time. You may also call us at 1-800-541-8981 from 8 a.m. to 8 p.m. seven days a week.
Last updated 10/01/2009
