Member forms - Arkansas Blue Cross and Blue Shield 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Enrollee ID and Group Number, which can be found on your Arkansas Blue Cross and Blue Shield ID card.
3. Fill in your personal information including Last Name, First Name, Street Address, City, State, ZIP code, Date of Birth, and Sex.
4. Indicate if you have Other Health Insurance by selecting 'Yes' or 'No'. If applicable, provide the name and policy number of the other insurance.
5. Enter the Provider Name and their NPI/TIN. Specify the Date of Service and select the Procedure Description from options like Cleaning, Oral Exam, or X-ray.
6. Review all entered information for accuracy. Remember to complete one form for each enrollee and ensure you have original itemized bills ready for submission.
7. Sign and date the form at the bottom to certify that all information is true and accurate before mailing it to the specified address.

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