BCBSKS Member Disease and Wellness Enrollment Form

Member Info

Identification Number*

First Name*

Last Name*

Date of Birth*

Street 1*

Street 2

City*

State*

ZIP Code*

Contact Info

Home Phone *

Cell Phone *

Work Phone *

Work Extension

Email Address*

Confirm Email Address

* Please enter at least one phone number.

Disease and Wellness Management

We will call to schedule your first appointment with your nurse. The best way and time to reach me is:

Contact Preference

Preferred Time (CST)* **

We will call you within one week after you submit this form.

Comments (optional)

This information is confidential. Only authorized Blue Cross and Blue Shield of Kansas employees will have access to this information. For more information call 800-520-3137 between 8 a.m. and 4:30 p.m., Monday through Thursday, and between 7 a.m. and 3:30 p.m. Friday.

** Once you are enrolled in a program, nurses are available to speak with you until 9 p.m. by appointment.

Disease and Wellness Management Enrollment Success

Form Submission Success

Thank you for your interest in our disease and wellness management program. An enrollment specialist will contact you at your preferred method of contact within one week.

Your confirmation number is:

Disease and Wellness Management Enrollment State Group

State of Kansas employees aren't eligible for this program. Please contact your human resources department for information about similar programs available to you.

Disease and Wellness Management Enrollment State Group

Members who have our Medicare supplemental plans aren't eligible for this program. Please contact your primary health care insurer for similar programs available to you.

Disease and Wellness Management Enrollment Error

Internal Server Error

Unable to submit the form due to an Internal Error. Please try again later.

Disease and Wellness Management Enrollment Form

Member Info

Contact Info

Disease and Wellness Management

Form Submission Success

Internal Server Error