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Regence BlueShield Individual Marketing Supplies Order Form

Please allow seven (7) business days for delivery. If you have not received your order in this time frame, please contact your Sales Representative for assistance. Please do not re-enter your order as this could result in additional delays. Thank you.

	Regence Individual Sales Packet Includes: Plan Summaries for Breakthru, Selections, PPO, HSA, and DentalOne, Product, Enrollment Forms, Rates, and Washington State Health Questionnaire *Includes August 2008 rates.*
	Regence Breakthru Brochure Includes: Breakthru Plan Rates, Summary of Benefits, and Overview.
	Regence Individual Compare Brochure
	2008 RBS Breakthru 50 Plan Summary (Spanish)
	2008 RBS Breakthru 50 Plan Summary (Spanish)
	2008 RBS Breakthru 80 Plan Summary (Spanish)
	Regence Request to Change Form Includes: Request to Change Form and Business Reply Envelope
	Regence DentalOne Sales Packet Includes: DentalOne Plan Summary, Rates, Enrollment Form, Mailing Envelope, and Business Reply Envelope
	Standard Health Questionnaire for effective dates of April 1, 2008 or greater Includes: Washington State Health Questionnaire and Business Reply Envelope
	RBS Individual Application (rev 7/08) - (Ind: 01,08) Includes: Enrollment Application and Business Reply Envelope
	Regence Electronic Funds Transfer Form(EFT) Includes: EFT Form, Mailing Envelope, and Business Reply Envelope
	Regence Selections Provider Directory
	RBS PPO Provider Directory (rev 05/08) - (Ind: 22)

Regence Medicare Supplies

	Regence Medicare Supplement Sales Packet Includes: Outline of Coverage, Rates, Enollment Application, Plan Overview, and Notice of Replacement Form
	RBS Medicare Supplement Application (rev 1-08) - Effective (1/07) - (Med: 02,09) Includes: Regence Medicare Supplement Enrollment Application and Business Reply Envelope
	Regence Electronic Funds Transfer Form(EFT) Includes: EFT Form and Business Reply Envelope
	Regence Notice of Replacement Includes: Notice of Replacement Form and Business Reply Envelope
	Regence MedAdvantage Sales Packet Includes: Summary of Benefits Booklet, Plan Outline, Enrollment Form, Provider Directory, Information Checklist, SurePay Authorization Form, and Business Reply Envelope
	MedAdvantage Enrollment Form Effective June 2008
	Asuris Script Medicare Part D Sales Packet Includes: Summary of Benefits Booklet, Medicare Drug Plan Brochure, Enrollment Form, Information Checklist, SurePay Authorization, Business Reply Envelope


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Order materials by filling in the quantities desired Please allow 7 business days for delivery

Should you need materials not listed on this page, please contact Individual Marketing at 1 888 344 8234, or your Sales representative.


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