IFP Forms and Applications

Medical, specialty, and Life applications

Medical plan applications

This application will allow you to apply in our medical plans and our Specialty plans (dental and vision plans) at the same time. For faster processing of English applications, save time and enroll your clients through our Quote & Apply tool below. Your bonus and commissions are accounted for.

Adding dependents

Dependents can be added during Open Enrollment, or during a special enrollment period due to a qualifying event. In most circumstances, you cannot use the Quote and Apply tool to properly enroll new dependents on an existing plan/policy. Please contact us for assistance with enrolling and/or enrollment questions about:

  • a qualifying parent/stepparent
  • adding child dependents to an existing plan/policy
  • adding a spouse/domestic partner to an existing plan/policy

New enrollment

Application for Blue Shield individual and Family Health Plans, English (Quote and Apply tool)

Application for Blue Shield Individual and Family Health Plans, Spanish (PDF, 776 KB)*
Application for Blue Shield Individual and Family Health Plans, Chinese (PDF, 1.3 MB)*
Application for Blue Shield Individual and Family Health Plans, Korean (PDF, 1.2 MB)*
Application for Blue Shield Individual and Family Health Plans, Vietnamese (PDF, 908 KB)*

Specialty plan applications

Get an enrollment application for your clients who want to only enroll in a Blue Shield dental plan and/or vision coverage.

Adding dental and vision plans to an existing policy

Current members can add dental and vision plans sold through Blue Shield to their existing policy by logging into their account and going to the Benefits page.

New enrollment

Dental, vision, and dental + vision package application, English (Quote and Apply tool)

Dental, vision, and dental + vision package application, Spanish (PDF, 1.1 MB)* 
Dental, vision, and dental + vision package application, Chinese (PDF, 1.3 MB)* 
Dental, vision, and dental + vision package application, Korean (PDF, 1.3 MB)* 
Dental, vision, and dental + vision package application, Vietnamese (PDF, 1.2 MB)*

Individual Term Life Insurance (ITL)​

Make sure your clients are protected by adding individual term life insurance (ITL) to their portfolio of coverage with benefit amounts ranging from $10,000 to $100,000 including Accidental Death and Dismemberment (AD&D) coverage. ITL can be purchased with or without a medical, vision or dental plan, or AD&D coverage. However, AD&D coverage must be purchased with ITL coverage.

Learn more and apply for ITL coverage

Claim forms

Subscriber's Statement of Claim form (PDF, 103 KB)
(Subscribers should use this form only when the provider of service does not submit a claim directly to Blue Shield)

Subscriber Claim form for Services Received Outside California (PDF, 100 KB)

International Claim form (PDF, 114 KB)
Download the Blue Shield Global Core International Claim form.

Dental Claim form (PDF, 168 KB)

Vision Claim form (PDF, 419 KB)
Download a vision claim form for members using an out-of-network provider.

Life Insurance Claim form (PDF, 89 KB)
Download this claim form for clients with life insurance claims that require a Proof of Death.

Authorization for the Release of Health information (PDF, 119 KB)

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.