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Individual & Family Products


How do I apply for CHIP?

There are three ways to apply for CHIP:


Paper Application

  • Call 1.800.KIDS.101 (1.800.543.7101) to request an application be mailed to you.
  • Download and print the application in a PDF format using the buttons at the bottom of this page. The application is large and takes several minutes to download over a dial-up internet connection. You will need Adobe Acrobat Reader installed on your computer to open the file. You cannot submit this application online.
  • You may request an application be sent to you using the following email address: Include your name and mailing address in the email.

How do I complete the application?

  • Complete one application which will cover all children who are under 19 years of age and living in the household.
  • Include the following individuals on your application, whether you are applying for them or not:
    • Yourself
    • Your spouse or unmarried partner
    • Anyone under 21 who lives with you
    • Anyone you include on your tax return, even if they don’t live with you
  • Be sure to answer all questions. An incomplete application will delay processing.
  • If any documentation is needed in order to process the application, it will be noted on the application.


Where should I send the completed application?

Capital BlueCross
PO Box 777014
2500 Elmerton
Harrisburg, PA 17110-9956

Or fax it to 717.651.8592


Apply Online


CHIP Application Forms for download