HOW TO COMPLETE YOUR HIGHMARK BLUE CROSS BLUE SHIELD ENROLLMENT APPLICATION 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employee Information section. Enter your Employer Name and select the Reason for Application from the provided options.
3. Complete your personal details including First Name, Middle Initial, Last Name, Street Address, City, State, and Zip Code.
4. Provide your Social Security Number and Effective Date of Coverage. Indicate your Employee Status by checking the appropriate box.
5. Fill in your Home and Work Phone Numbers for contact purposes. Also, include your Hire Date.
6. Select the Type of Coverage you are enrolling in (employee, two person, or family).
7. For items 15 through 18, provide information about yourself and each eligible family member. Ensure all requested fields are completed accurately.
8. In the Physician of Record section, choose a physician from the Online Provider Directory and provide their details as required.
9. If applicable, complete the Medicare Information section for any family members eligible for Medicare benefits.
10. Finally, sign and date where indicated to complete your application. Retain a copy for your records.

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