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Individual & Family Products


How do I apply for CHIP?

There are three ways to apply for CHIP:


Please note that although the applications and renewal forms include language stating that you must mail or fax proof of current income, you are NOT required to forward proof of income in with any application. We will attempt to verify all income through the use of electronic databases. If we cannot verify income electronically, we will contact you to request paper income documentation. If we request income documentation, you will be responsible to provide it to complete your application or renewal.

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 also apply 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