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.

Network Information and Maps

2020 Network Information and Maps

Southwest Region Plans 20-013SW
Eastern Region Plans 20-013EA
Central Region Plans 20-013CE
North and North Central Region Plans 20-013NO

QHP Applications and Change Forms

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.

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

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

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

2020 Application Forms

North Region

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

Southwest Region

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

East/Southeast Region

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

Grandfathered and Grandmothered

Short Term

General Maintenance Forms

Authorization Agreement for Automatic Withdrawal 3-449
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.