BlueCross & BlueShield of Tennessee
Serving our customers for over 18 years!

To insure the most accurate and timely quote, please answer all fields.

 

Individual or Family Health Insurance Plan

For TN Residents ONLY

Name:

Address:

City:

State:

Zip:

County:

Email:

Home Phone:

Date of Birth:

MONTH

DAY

YEAR

Gender:

Male

Female

Tobacco Use:

Yes

No

Taking Medication:

Medication, Strength & Frequency:

If you or your  dependent (s) bas been diagnosed or treated or had any recommendation for treatment for any of the following please indicate with a yes.

HIV positive, AIDS, or other immune system disorder?

Yes

No

Kidney or Liver disorder (excluding kidney stones)?

Yes

No

Cancer?

Yes

No

Heart attack, congestive heart failure, or serious hearing disorder?

Yes

No

Nervous and mental disorder or disabilities requiring hospitalization?

Yes

No

Alcohol or drug abuse treatment within the last 5 years?

Yes

No

Emphysema or Tuberculosis?

Yes

No

Asthma Hospitalization within the last 3 years?

Yes

No

Diabetes requiring prescription medication?

Yes

No

Diabetes--diet controlled and NOT requiring medication?

Yes

No

Maternity (currently pregnant)

Yes

No

Spouse:

Yes

No

Spouse Date of Birth:

MONTH

DAY

YEAR

Spouse Gender:

Male

Female

Spouse Tobacco Use:

Yes

No

Taking Medication:

Medication, Strength, & Frequency:

Number of Children:

Date of Birth & Gender  of Children:
Ex. (02-14-1999)

Male

Female

Male

Female

Male

Female
 

 

Male

Female

Male

Female

Male

Female

Taking Medication:

Medication, Strength, & Frequency:

Other Health Insurance:

Yes

No

 If Yes,

Deductible Amount:
$500

$1000

$1500

  


$2500

$5000

  


 
Consumer Health Association
PO Box 3692
Brentwood, Tennessee 37024
Toll Free 1-800-613-9193
Local 1-615-360-1125
Fax 1-615-329-1942