Regence BlueShield of Idaho 2025

1. Click ‘Get Form’ to open the Regence BlueShield of Idaho application in the editor.
2. Begin by filling out the Group Administrator section, including the Health Group Number, Subgroup, Class, Group Name, and Requested Effective Date. Ensure all fields are completed accurately.
3. In SECTION 1, indicate whether this is a New Enrollment, Change, or Cancellation. Select the appropriate reason for enrollment and provide relevant dates.
4. Proceed to SECTION 2 to enter Employee Information. Fill in personal details such as Last Name, First Name, Mailing Address, Date of Birth, and Social Security Number.
5. In SECTION 3, list any dependents you wish to enroll. Provide their names, relationship to you, and other required information.
6. Complete SECTION 5 by detailing any current or prior coverage information for each individual listed on the application.
7. Finally, review SECTION 6 for the Applicant Signature. Ensure all information is accurate before signing and dating the form.

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