Please select an option below:

• View or download forms.

  NE CHIP Application Form CHIP Claim Form Deductible Change Request Form Address Change Form Health Savings Account (HSA) Request Form Authorization for Release of Protected Health Information Debit Authorization

• Request an application packet by mail.
  1. First Name(required)
  2. Middle Initial
  3. Last Name(required)
  4. Address 1(required)
  5. Address 2
  6. City(required)
  7. State(required)
  8. Zip(required)
  9. Daytime Phone
  10. Quantity 1 2 3 4 5 6 7 8 9 10 (required)

   

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• Please call me.
  1. Your Name(required)
  2. Phone #(required)
  3. Best Time No Preference Morning Afternoon Evening

   

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• Email a question to NECHIP.
  1. Email(valid email required)
  2. Message(required)

   

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• I am an Agent/Insurance Broker. Please send me more information.
  1. Your Name(required)
  2. Company(required)
  3. Address(required)
  4. City(required)
  5. State(required)
  6. Zip Code(required)
  7. Telephone(required)

  Quantities

  1. CHIP Enrollment Application, Form No. 3049 0 1 2 3 4 5 6 7 8 9 10
  2. CHIP Rate Schedule, Form No. 8246 0 1 2 3 4 5 6 7 8 9 10
  3. CHIP PPO Plan Brochure, Form No. CHIP-20 0 1 2 3 4 5 6 7 8 9 10
  4. A Guide to Your Prescription Drug Benefits Brochure, Form CHIP No. 26 0 1 2 3 4 5 6 7 8 9 10
  5. Mellon HSA Decision Guide & Request Form, Form Nos. 2007
     Mellon HSA HIW & 37-044 0 1 2 3 4 5 6 7 8 9 10
  6. Courtesy Reply Envelopes, Form No. 766 0 1 2 3 4 5 6 7 8 9 10
  7. Other - Please State
  8. Quantity 0 1 2 3 4 5 6 7 8 9 10

   

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NEBRASKA COMPREHENSIVE HEALTH INSURANCE POOL
Local: 402-343-3574
Toll Free: 1-877-348-4304
8:00 am to 4:30 pm Monday through Friday

Fax Number: 402-398-3640

Please send all premium payments to:

Blue Cross Blue Shield of Nebraska
ATTN: CHIP
PO Box 3248
Omaha, NE 68180-0001

NE CHIP Program, a comprehensive health insurance pool, online services include links to government and nonprofit health organizations, premium rate calculator and eligibility information.