* If you are a Medicaid or Child Health Plus member, please login here.
All plans require selection of a Primary Care Physician (PCP). Click here to find a doctor.
Please select an effective date from the available options.
During the annual Open Enrollment period, which runs from November 1, 2019 through January 31, 2020, you may apply for coverage, or members can change plans.
If you do not enroll during open enrollment, or during a special enrollment period, you must wait until the next annual open enrollment period to enroll.
Note: If you have multiple children and would like to provide each
of them with pediatric dental coverage, then you will have to complete a separate
version of this application for each child.
Note: If you have multiple children and would like to provide each of them with
pediatric dental coverage, then you will have to complete a separate version of this application
for each child.
The selected coverage is available as child only coverage.
Do you want to continue enrolling using the child only version of this plan?
Note: If you have multiple children and would like to provide
each of them with a child only plan, then you will have to complete a separate version of this
application for each child.
If you answered "no", we will provide coverage of the pediatric dental essential health benefit. Additional
premium will apply.
We think that your address may be incorrect or incomplete.
To proceed, please choose one of the options below.
Note: Suggested address corrections are highlighted in red.
Click on any of the text headings below to open a section that contains a form that you can fill out for each of your dependents.
To be completed by your BlueCross BlueShield of Western New York appointed agent/broker:
Include your street address, suite no., and personal mailbox (PMB) no. if available
Agent / Broker Signature
I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE RESPONSES HEREIN ARE ACCURATE.
I agree, and it is my intent, to sign this form and submit my application by writing my name on the form and by electronically submitting this application. I understand that my signing and submitting this application is the legal equivalent of having placed my hand written signature on the application. I understand and agree that by electronically signing this application in this way, I am affirming to the truth of the information contained in this application.
Use your mouse to sign your full name below to complete enrollment.
I AUTHORIZE ANY LICENSED DOCTOR, HOSPITAL OR OTHER HEALTH CARE PROVIDER TO PROVIDE MY PLAN WITH ANY INFORMATION OR DOCUMENTS REQUESTED CONCERNING MEDICAL SERVICES I OR MEMBERS OF MY FAMILY HAVE RECEIVED, WHICH THE PLAN DETERMINES IS NECESSARY FOR THE OPERATION AND REGULATION OF THE PLAN. THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND IS VALID FOR UP TO 24 MONTHS. * ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Please review your online enrollment application information before submitting. If you find any
issues, you can close this dialog and navigate back to the step the issue is
on and fix it there.
Thank you for choosing BlueCross BlueShield of Western New York.
Before you begin please have the following information for each applicant:
We can help you find out if you qualify for a subsidy to help pay for your health plan. Contact one of our benefit consultants at 1-800-888-5407 for more information.
If you are enrolling with a domestic partner, proof of the domestic partnership and financial interdependence must be submitted prior to the enrollment being complete. Download the Affidavit of Domestic Partnership.
If you are enrolling a dependent and are choosing the age 29 rider, an additional form must be submitted before the enrollment can be completed. Please contact Customer Service at 1-855-344-3425 to have the form mailed to you, or a form will be mailed once we receive your application.