Healthy Options Enrollment Form

This free program is designed to help members, ages 21 to 63, who have BCBSKS as their primary carrier. If Medicare is your primary we cannot enroll you in Healthy Options; please contact Medicare to see if they have a similar program.

* Required Fields
Member Info: *
Member Identification Number:
First Name:
Last Name:
Date of Birth: (mm/dd/yyyy)
Street 1:
Street 2:
ZIP Code:
Contact Info:*
At least one phone number*
(area) - (phone)
Home Phone: -
Work Phone: - Ext:
Cell Phone: -
(E-mail is Optional)
Verify e-mail:

Chronic Disease (Check at least one):*
COPD Diabetes Asthma
Heart Disease High Blood Pressure High Cholesterol

Please, give us the best time to reach you between the hours of 7:30 a.m. and 6:30 p.m. Central Time. *

Contact Preference: Preferred Time:

Comments: (Maximum characters: 255)
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This information is confidential. Only authorized Blue Cross and Blue Shield of Kansas employees will have access to this information. Want more information about our free Healthy Options disease management program? E-mail or call 1-800-520-3137.