| Downloadable Forms |
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Please select one of the links below to view that form.
| Form Name |
Form Number
|
PDF Size |
| Coverage Change Termination Form |
|
33 kb |
| Enrollment Application/ Change Form |
TDI#: EE/CHG3 1003
|
205 kb |
| Solicitud de Inscripción Grupal/Instrucciones para el Formulario de Cambio |
TDI#: EE/CHG3 1003
|
541 kb |
| Medical Claim Form |
|
18 kb |
| Medical Claim Form - Spanish Version |
|
72 kb |
| Dental Claim Form |
|
137 kb |
| Dependent Addition and Change Form for Court Ordered Dependents |
TDI#: GDA-CMHC-02
|
25 kb |
| Dependent Child Statement of Disability |
TDI#: DISABILITY02
|
19 kb |
Small Group Employer Application
(rev 03/08)
For quotes entered after 04-12-08 for new accounts effective 07-01-08 and after. |
TDI#: SERA24
|
210 kb |
Small Group Employer Application for Amendment (rev 03/08)
For changes for new accounts entered after 04/12/08 for new accounts effective 07-01-08 and after. |
TDI#: SERA24A
|
160 kb |
Small Group Employer Application (rev 03/07)
For quotes entered after 05/15/07 for new account effective 7/1/07 and after |
TDI#: SERA23
|
325 kb |
Small Group Employer Application for Amendment (rev 03/07)
For quotes entered after 05/15/07 for new account effective 7/1/07 and after |
TDI#: SERA23A
|
248 kb |
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. |
|
104 kb |
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. |
|
106 kb |
Group Administered 6 Mth Continuation Application
Form #GroupAdmin06, 43936.1106 (rev 11/06)
Note: If HCSC (Blue Cross Blue Shield of Texas) administers Texas State Continuation as a Third Party Administrator for your group do not use this form. Please call (888) 541-7107.
Application for Group Benefit Officers to request an additional 6 months of coverage after COBRA has expired or as an initial request for continued coverage for smaller groups not subject to COBRA regulations. |
|
90 kb |
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. |
|
38 kb |
HR Forms
Medicare Secondary Payer Forms
| Form Name |
Form Number
|
PDF Size |
| Instructions - Completing the Annual MSP Employer Acknowledgement Form |
TDI#: 21088.0207
|
59 kb |
| Annual MSP Employer Acknowledgement Form |
TDI#:
21084.0507
|
48 kb |
| Information Regarding the Medicare as Secondary Payer Statute |
TDI#: 21092.0207
|
64 kb |
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 refer to the Instructions - Completing the Annual MSP Employer Acknowledgement Form. 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. |
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