Customer Service Request Form

For all questions and requests for more information, please contact one of our representatives. Please allow up to two business days for a reply; if you need information now, please contact Customer Service by telephone from 6:00 a.m. to 6:00 p.m. Monday through Friday. Note: Replies received from Regence will not resemble this form as our secure routing server changes the e-mail header.

(* indicates required fields)

Member Number:

(See Regence member card)

*Name:

First, MI, Last

*Comments & Questions:

If you would like us to contact you regarding this message, we will need a way to get in touch with you. Please provide information on any of the following:

*Address:

Address Line 2:

*City:

*State:

*Zip:

Phone:

Fax:

*E-mail:

I do not want to be contacted by an authorized Regence BCBSO agent at this time.

I certify that I am "the member" or "an enrollee on this plan" or "a registered custodial parent of a dependent on this plan"

All our replies are sent via secured server and if you experience difficulty in accessing the reply due to security restrictions by your Internet service provider, please contact that provider to resolve the problem..