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Individual and Family Plan Applications

Medical Plan Application

Explore your plan options, determine your eligibility for financial assistance, get a quote, and apply for a Blue Shield individual or family plan.

Individual and Family Plan Application

Dental Plan Application

Current or prospective members should use this application to apply for dental and vision coverage.

Individual and Family Plan Dental Application (PDF, 197KB)


Release of Personal Health Information

Authorization for the Use or Disclosure of Health Information

Submit this form to authorize Blue Shield to release your personal and health information according to your instructions. To protect your privacy, Blue Shield requires authorization to release your information.

English (PDF, 119KB)
Spanish (PDF, 121KB)
Vietnamese (PDF, 248KB)
Chinese (PDF, 347KB)
Hindi (PDF, 154KB)
Korea (PDF, 229KB)

 


EZ Pay

EZ Pay Form

In order to make changes to your monthly premium, log into your Blue Shield account and access the Payment Center tab. You may also call Customer Service at (888) 256-3650.


Beneficiary

Beneficiary Change Request

Submit this form to add or delete beneficiaries from a term life insurance plan.

Beneficiary Change Request (PDF, 455KB)

Beneficiary Affidavit

Submit this document when no beneficiary was designated or no designated beneficiary survived the deceased insured.

Beneficiary Affidavit (PDF, 455KB)


Proof of Death Forms

Individual and Family Plans

Beneficiaries should submit this form for proceeds after an insured dies. When submitting the form, include an original certified death certificate.

Individual and Family Plan Statement and Notice of Death (PDF, 468KB)

Group Plans

Group Administrators should submit this form after an employee with Life Insurance dies. When submitting the form, include an original certified death certificate, proof of beneficiary designation, and proof of eligibility.

Proof of Death (PDF, 454KB)


Claims

Accelerated Death Benefit Claim

When an insured person becomes terminally ill before age 60, they may receive life benefit proceeds prior to death. Before submitting this form, please see plan benefits for specific eligibility.

Accelerated Death Benefit Claim (PDF, 451KB)

Dismemberment Claim

Submit this form when the insured is making a dismemberment claim in conjunction with their Accidental Death & Dismemberment coverage. 

Dismemberment Claim (PDF, 448KB)


Vision Benefit Claim

Take this form to your appointment to file a claim when obtaining services from a vision provider that is not in the MESVision provider network.

Vision Benefit Claim (PDF, 73KB)


Life Insurance Forms

Additional Contact Designation

For Individual and Family Plan Subscribers: Complete this form to add an additional contact person(s) to receive a notice of lapse or termination of your life insurance policy if your premium is not paid.

Life Insurance Additional Contact Designation form (PDF, 1MB)


Continuity of Care

Continuity of Care Brochure

English brochure (PDF, 1.6MB)
Spanish brochure (PDF, 1.6MB)
Vietnamese brochure (PDF, 1.8MB)
Chinese brochure (PDF, 2.0MB)
Hindi brochure (PDF, 1.7MB)

 

Continuity of Care Application

English application (PDF, 1.7MB)
Spanish application (PDF, 2.7MB)
Vietnamese application (PDF, 1.9MB)
Chinese application (PDF, 2.0MB)
Hindi application (PDF, 1.7MB)