Paper Enrollment

You can either print the paper enrollment form and fill it out by hand, or open the form on your computer and type the information into the form.

Download, print, then complete the form by hand:

  1. Go to the enrollment forms area of the documents section and get the form.
  2. Select the "paper form" link, then download and print the document.
  3. Print your information legibly in each section.
  4. Sign and date the form on page 4.
  5. Keep a copy for your records.
  6. If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
  7. Send the original form with your signature to the address listed at the beginning of the form.

Fill out the form on your computer using your keyboard and mouse:

  1. Go to the enrollment forms area of the documents section and get the "fillable" form.
  2. Use your mouse or tab key to move from one part of the form to the next. Click on a box to check it. Use the tab key to move from one fill-in area to the next, such as from the name fields to Birth Date on the enrollment form or Member Number on the form.
  3. Save it to your computer using “SAVE AS” and give it a new name. You will not be able to save it to BasicBlueRx.com.
  4. Type your information in each shaded box (click “Highlight Fields” at the top of the form to see the shaded areas you need to complete).
  5. Once you’ve entered all of your information, print the form.
  6. Sign and date the form on page 4.
  7. If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
  8. Keep a copy for your records.
  9. Send the original form with your signature to the address listed at the beginning of the form.