CITY OF BROCKTON

Department of Human Resources

 

 

 

BCBS Enrollment Form

Before you begin please carefully read the instructions below.

For members of HMO Blue, Network Blue, Blue Choice, HMO Blue New England, or Blue Choice New England: You’re required to choose a primary care physician (PCP) when you enroll. Please choose a PCP from your plan’s provider directory. Be sure to read “PCP ID #” in Section 2. List your PCP choice on your enrollment form. The PCP ID number can also be found by visiting bluecrossma.org and selecting Find a Doctor.

For Access Blue Members: Although you’re not required to choose a PCP, we recommend you choose one by following the instructions in Section 2 on the back of this page.

Important: Are you covered by Medicare or other insurance? We need to know if you or any family member listed have Medicare and/or other insurance in addition to your Blue Cross Blue Shield of Massachusetts plan. Please be sure to check either Y (for yes) or N (for no) in the correct box. This information will help us accurately coordinate your benefits. Please follow the instructions in Sections 2 and 3.

Please print two copies of your completed application. Keep one for your records and give the other to your employer to sign and mail to Blue Cross Blue Shield of Massachusetts. In order to complete your enrollment request, your employer is required to sign the application.

Special Instructions for Student Coverage: If you’re seeking coverage for a full-time student dependent over age 19, you may need to fill out a Student Certificate form. Check with your employer to see if this coverage is available.

Click the link below to fill out the form
Blue Cross Blue Shield Enrollment Form