Individual Documentation

The Blue Cross of Idaho forms for Individual new sales and ongoing client support are located in the list below.

We encourage online enrollment whenever possible, as it speeds up the application processing time, which provides your client access to their benefits on their coverage effective date. If it is necessary to submit paper enrollment applications, please remember to submit accurate, legible and complete information. Send individual enrollment information to iss@bcidaho.com.

QHP Applications and Change Forms

online-fillable form Online-fillable form

New applicants use the Idaho Individual Application & Cover Sheet for their region. To choose the correct application, please refer to the region by county list below. The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

2019 Application Forms

North Region - For residents of the following counties: Adams, Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties

Idaho Individual Application & Cover Sheet – North Region  20-020
Qualified Health Plan Products Change Form – North Region  20-023

Southwest Region - For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, Custer, Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties

Idaho Individual Application & Cover Sheet – SW Region  20-021
Qualified Health Plan Products Change Form – SW Region  20-024

East/Southeast Idaho Region - For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia, Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties

Idaho Individual Application & Cover Sheet – East/SE Region  20-019
Qualified Health Plan Products Change Form – East/ SE Region  20-022

 

2018 Application Forms

North Region - For residents of the following counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties

Idaho Individual Application & Cover Sheet – North Region online-fillable form 3-1179
Qualified Health Plan Products Change Form – North Region online-fillable form 3-1182

Southwest Region - For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, (for CarePoint St. Luke’s Health Partners plan applicants), Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties

Idaho Individual Application & Cover Sheet – SW Region online-fillable form 3-1180
Qualified Health Plan Products Change Form – SW Region online-fillable form 3-1183

East/Southeast Idaho Region - For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia (for Hometown East plan applicants), Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties

Idaho Individual Application & Cover Sheet – East/ SE Region online-fillable form 3-1178
Qualified Health Plan Products Change Form – East/ SE Region online-fillable form 3-1181

Grandfathered and Grandmothered

Medicare Supplement

Short Term

online-fillable form Online-fillable form

Short Term PPO Application 20-048A

General Maintenance Forms

online-fillable form Online-fillable form

Authorization Agreement for Automatic Withdrawal 3-449
Authorization to Delete Dependent  
Certification of Non-Use of Tobacco 3-319
SEP Validation Form (Validation of Qualifying Life Event)  
Residency Validation Form (Validation of Idaho residency)  
New applicants can apply using the Idaho Individual Application & Cover Sheet for their region. To choose the correct application please refer to to the region by county list below.
The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.