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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 can complete the application online before you print it. 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.
  • Include appropriate income documentation. An application that is submitted without income documentation is considered incomplete.
  • If any other documentation is needed in order to process the application, it will be noted on the application.

Acceptable forms of income documentation are:

  • Employment at least one of your most current pay stubs. If pay stubs are not available, your employer can provide a letter that indicates your gross income and how often you are paid. This letter should be on company letterhead. W-2s or other tax forms are not acceptable (except if you are self-employed see below).
  • Unemployment Compensation a copy of the most current award letter that indicates your weekly benefit amount. If you have access to a computer, a printout from the Department of Labor and Industry of your disbursements over the last month is preferred.
  • Self-Employment the most recent Federal Income Tax Return including all schedules and forms associated with that tax return or a year to date Profit and Loss Ledger showing gross profit, expenses, and net profit (1099 Forms are not acceptable).
  • Dividends/Interest a copy of the most current Federal Income Tax return, a copy of the most current 1099 tax form, or a statement from the financial institution.
  • Social Security please provide a copy of the Benefit Award letter. If you do not have a copy of the award letter you can request a copy.
  • Pension/Retirement please provide a copy of the most current award letter or most current pay stub.
  • Alimony please provide at least one of the most current check stubs, a bank statement, or the disbursement statement.
  • Other must have current documentation as proof of other income.

Income documentation must be from within the last 60 days, except in an instance where it is appropriate to send a tax form. Income documentation must show the amount of income you receive before taxes and other deductions. If there are any special circumstances regarding your income, please explain in detail on a separate sheet of paper. If you are mailing, separately from the application, any income or other documentation needed please be sure to include your name or your child's name on the documentation.

Please be sure to send copies of the income documentation. Originals will not be returned.

Where should I send the completed application and/or income documentation

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