Regence BlueShield     Evolve Plus     Evolve Core   HSA Plans     Evolve HSA 50     Evolve HSA 80     Evolve HSA 100   Plan Rates   Apply Now!   Provider Directory   Waiting Period     & Exclusions   FAQ's   LifeWise of WA   Group Health   HSA Plans     HSA Overview     Qualified Expenses     Regence HSA Plans     LifeWise HSA Plan     Group Health HSA   Individual Dental   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application		(Available to Washington State Residents Only) Regence BlueShield HSA Application Process and Forms Use these forms and instructions if you are applying for any of the Evolve HSA plans. If you wish to apply for either the Evolve Plus or Evolve Core plans, click here for the Regence (non-HSA) application process and forms page. To apply for any of the Regence HSA individual medical plans, please complete the following steps: Fill out the Regence Application (one per family) Click here to download the Regence BlueShield Individual/Family Enrollment Application. Print the application and fill it out completely. or Click Here to Enroll On-Line Fill out the HSA Application & Forms (one per family) Click here to enroll on-line (fastest way to set up an account) or Click here to print the HSA Application Packet and mail it in. Fill out the Questionnaire (one for each person to be covered) Click here to download the Standard Health Questionnaire for Washington State. Print and complete the questionnaire for each person to be covered on the plan. Please refer to Completing the Health Questionnaire to determine if this applies. Provide Proof of Washington State Residency To be eligible to purchase this plan you must be a Washington state resident. A photocopy of one of the following must accompany your application to prove residency: Valid Washington State Driver's License or Identification Card Washington State Voter Registration Card Current Utility Bill in your name, including address Provide Certificate of Creditable Coverage (if available) Please refer to Credit for Prior Coverage & HIPPA Eligibility for more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Regence BlueShield. Do not Send a Payment Please do not send a rate payment with your application. You will receive a statement from Regence BlueShield upon acceptance of your application. Send all Enrollment Materials to: Regence Blue Shield P.O. Box 1107 1602 21st Ave Lewiston, ID 83501 Please note: Regence Blue Shield requires all COMPLETED enrollment materials to be postmarked to their office on or before the 20th of the month. Incomplete enrollments may cause delays in the effective date of your coverage. Please refer to the checklist on the application to avoid delays. For Example: If you wanted your medical insurance coverage to begin on June 1, you would need to send all of the required, completed enrollment material to Regence Blue Shield postmarked on or before May 20. E-mail us for more information and a free quote or CALL TOLL FREE 1-800-875-4490 (in the U.S.) or 1-253-854-0199 (outside the U.S.) Fax: 1-253-896-9411 Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424 Serving all of Washington at 800-875-4490, Seattle at 206-682-1628, Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291. Copyright© 1998-2011, Maddock & Associates  |  Privacy Statement Problems viewing this page? Contact the webmaster.