Individual and Family Online Application

Healthy SmilesSM Individual and Family Online Application

Please provide us the information requested below, e.g., name and address.

For questions, please contact a sales representative at your local district office (800) 365-2345.
:: Applicant Information ::
* required field.
* First Name
* Last Name
* Email Address
* Idaho resident?
* Marital Status * Gender
* Birth Date
 /   / 
* Social Security Number
   Why do we need this?
*Mailing Address (street or route) * City * State * Zip Code County
Is your billing address the same as your mailing address?
* Home Phone No.
 )   - 
Work Phone No.
 )   - 
Other Coverage Information
* Is this person now covered, or has he or she been covered by any other dental insurance?
* Is this person now covered by a medical health insurance policy?
We request your Social Security number on this application because federal law requires all health insurers to report specific group and member information to the Center for Medicare & Medicaid Services (CMS). This includes the Social Security number for members and their dependants.

Blue Cross of Idaho has adopted policies, procedures and practices to safeguard the security and confidentiality of personal information including Social Security numbers.