Downloadable Forms

Please select one of the links below to view that form.

Form Name	Form Number	PDF Size
Coverage Change Termination Form		33KB
Enrollment Application/Change Form	TDI#:  EA/CF 1012	214KB
Enrollment Application/Change Form — Spanish	TDI#:  EA/CF 1212SP	222KB
Away From Home Care Guest Membership Application (for HMO members)  HMO members can use this form to apply for guest membership at a Host HMO when residing outside their home plan service area for 90+ consecutive days. Please read and follow the instructions on the form.	N/A	314KB
HMO Blue® Texas Medical Claim Form	8708.995-102	19KB
Medical Claim Form	1081.000-901	19KB
Medical Claim Form - Spanish	1081.000-901 SP	73KB
Dental Claim Form		137KB
Prescription Drug Claim Form (for Group Plan members)  BCBSTX members with pharmacy benefits through an employer group insurance plan can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSTX pharmacy benefits manager.	3272 TX	347KB
Prescription Drug Claim Form (for Individual Plan members)  BCBSTX members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSTX pharmacy benefits manager.	3272 TX IND	218KB
PrimeMail New Prescription Order Form  Members with BCBSTX prescription drug coverage can use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail, and include the original prescription signed by your doctor.	3208 TX NEW	237KB
PrimeMail Refill Prescription Order Form  Members with BCBSTX prescription drug coverage can use this form to mail order refills for prescribed maintenance medication.	3208 TX REFILL	360KB
Dependent Addition and Change Form for Court Ordered Dependents	TDI#:  GDA-CMHC-02	25KB
Disabled Dependent Certification Form	2487.000-202 02/02	394KB
Domestic Partner Affidavit  Submit a signed, notarized Domestic Partner Affidavit with the signed Enrollment Application/Change form to request dependent coverage for a domestic partner. Note: The employer group must have elected the Domestic Partner Coverage option for domestic partners to be eligible for coverage.		51KB
Small Employer Benefit Program Application (10/12)  For new groups with effective dates on and after Jan. 1, 2013.	TDI# TXBPASG19.12	512KB
Small Employer Benefit Program Application (Application for Amendment) (10/12)  For renewing groups with anniversary dates on and after Jan. 1, 2013.	TDI# TXBPASG1A9.12	282KB
COBRA Initial Notice Form #0009.443 (rev 08/04)   Employers are required to provide a COBRA Initial Notice when employees or their dependent spouses first become covered by a group health insurance plan subject to COBRA. In an effort to assist employer groups, HCSC has incorporated this notice into the Certificates of Coverage and Benefit Booklet. Although HCSC has taken this extra step, it is the employer group’s responsibility to make this notice available to each covered employee and to the employee’s spouse (if covered under the health insurance plan) not later than the earlier of: Either 90 days from the date on which the covered employee or spouse first becomes covered under the plan; or if later, the date on which the plan first becomes subject to the continuation coverage requirements; or the date on which the administrator is required to furnish an election notice to the employee or to his or her spouse or dependent.		104KB
Continuation of Coverage (COBRA) & COBRA Disability Form #COBRA06, 05253.1106 (rev 11/06)  Application for Group Benefit Officers to request continued coverage for employee due to employee's reduction in work hours, retirement, termination, etc. Application includes two sections; Application For COBRA First Qualifying Event and Application for COBRA Second Qualifying Event.		106KB
Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA)  This application is for members whose 18-month COBRA Continuation Coverage has ended, and who are eligible for an additional six (6) months of Continuation Coverage under Texas law. Use this form if your group administers its own COBRA Continuation Coverage. If BCBSTX is your group's COBRA Services administrator, please call 888-541-7107. If an outside Third-Party-Administrator (TPA) administers your continuation coverage, please contact your TPA.	53780.1011	127KB
Texas Nine (9) Month State Continuaton of Insurance Application Form  This application is for members who are not eligible for COBRA, but have the option to elect nine (9) months of Continuation Coverage under Texas law. Use this form if your group administers its own Texas State Continuation of Coverage. If BCBSTX is your group's Texas State Continuation of Coverage administrator, please call 888-541-7107.	53594.1011	127KB
Dependent State Continuation Form #StateContDep06, 43942.1106 (rev 11/06)   Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage for up to 36 months from loss of coverage due to divorce, death or retirement of the employee.		38KB

HR Forms

Form Name	Form Number	PDF Size
Change Life/ Beneficiary		213KB
Solicitud De Inscripcion De Grupo/ Cambio	TDI#:  EE/CHG3 1003SP	546KB
Student Certification	54545.06/11	43KB
Dependent Student Medical Leave Certification Form Leave Form	53947.01/11	32KB
Disabled Dependent Certification Form Leave Form	2487.000-202 02/02	394KB

Medicare Secondary Payer Information and Form

Form Name	Form Number	PDF Size
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	21125.0111 01/11	130KB
Information Regarding Medicare Secondary Payer (MSP) Statute	21092.0609 06/09	298KB
MSP Fact Sheet	56064.0612 06/12	389KB

Under federal law, it is the employer's responsibility to inform its insurer or third-party administrator of proper employee counts for the purpose of determining payment priority between Medicare and another insurer. Employer size, not group health insurance plan size, is used in determining whether the group health insurance plan or Medicare is the primary payer. For more details, please see the instructions with the Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions (above). In the absence of employer-provided employee counts, the Center for Medicaid & Medicare Services (CMS) requires that the employer's group health insurance plan coverage be considered primary to Medicare. To comply with this requirement Blue Cross and Blue Shield of Texas requires employer groups to complete the Annual MSP Employer Acknowledgement Form on a yearly basis. Additional information regarding the MSP statute is available in the document titled Information Regarding the Medicare as Secondary Payer Statute.