Employers | Brokers | Providers | Medicare | Medicaid | Member
Are you Medicare eligible?
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 below.
This 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.
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.
Reason for Enrollment/Change
Responsible Person Information
Primary Care Physician
Is this member a current patient? If not a current patient, have they verified that the PCP will accept them as a new patient?
Has this member obtained
stand-alone dental coverage for children under the age of 19 that
provides a pediatric dental essential health benefit through a
New York State of Health, the Official Health Plan Marketplace
(NYSOH)-certified stand-alone dental plan offered outside the NYSOH?
If you answered "no", we will provide coverage of the pediatric dental essential health benefit. Additional premium will apply.
Add Spouse/Domestic Partner
Do you have a spouse or a domestic partner to add to this plan?
Spouse/Domestic Partner Information
Notice! 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.
Dependent #1 Information
Dependent #2 Information
Dependent #3 Information
Dependent #4 Information
Dependent #5 Information
Dependent #6 Information
Dependent #7 Information
Dependent #8 Information
Dependent #9 Information
Dependent #10 Information
Dependent #11 Information
Dependent #12 Information
Dependent #13 Information
Dependent #14 Information
To be completed by your BlueCross BlueShield of Western New York appointed agent/broker:
Did you see the proposed applicant and spouse/domestic partner, if applying at the time this application was executed?
Include your street address, suite no., and personal mailbox (PMB) no. if available
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.
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.