Employer Offered Coverage Information and Forms
Get the most from your Employer Offered health insurance coverage by using these helpful forms and documents to make plan changes, add features and learn about other important ways to help manage your account.
These forms are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site. 
Note: If these downloadable PDF forms are altered in any way, they will not be processed by Blue Cross and Blue Shield of Texas (BCBSTX).
HMO Members Rights and Responsibilities
Employer Offered Coverage Forms to Return to HR
Photocopy and return these completed forms to your employer's human resource department. Keep a copy for your records.
|
Stock # / Date |
Downloadable Forms |
Texas Form # |
|
54521.1012 |
Enrollment Application/Change Form Existing BCBSTX group members must use this form to submit changes to their coverage or personal information such as: a name or address change, to add or drop dependents, or a change to their PCP election. New group members must use this form when enrolling in a BCBSTX group product offered by their employer. |
EA/CF 1012 |
|
54761.1212 |
Enrollment Application/Change Form - Spanish Same instructions as stated above for existing and new group members. |
EA/CF 1212 SP |
|
R2/07 X6053 |
Members who have life coverage through Group Life and Health/Dearborn National can use this form to change beneficiaries on their life policies. |
N/A |
|
43942.1106 |
Dependent State Continuation of Coverage Existing BCBSTX group members may request a continuation of coverage of their current benefits for up to 36 months if coverage is loss due to divorce, death or retirement of the employee. |
StateContDep06 |
|
2487.000-202 |
Disabled Dependent Certification Form BCBSTX members use this form if the dependent is incapable of self-support because of mental or physical impairment. |
N/A |
|
54545.0611 |
BCBSTX members can use this form to certify and report a dependent as a student. |
N/A |
Employer Offered Coverage Forms to Return to BCBSTX
Photocopy and return these completed forms to BCBSTX. Keep a copy for your records.
|
Stock # / Date |
Downloadable Forms |
Texas Form # |
|
1081.000-901 |
BCBSTX members who have PPO or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers. |
N/A |
|
1081.000-901 SP |
BCBSTX members who have PPO or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers. |
N/A |
|
8708.995-102 |
HMO Blue® Texas Medical Claim Form HMO Blue® Texas members can use this form to file claims for reimbursement that are not filed by their providers. |
MBRCLM102 |
|
N/A |
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 |
|
55352.0112 |
BCBSTX members with dental coverage can use this form to file dental claims for reimbursement that are not filed by their providers |
N/A |
|
N/A |
Dental Provider Nomination Form Please mail or fax this completed form to nominate a dental provider for inclusion in the dental provider network. |
N/A |
|
N/A |
Standard Authorization Form and other HIPAA Privacy Forms Members can provide authorization for BCBSTX to share Protected Health Information (PHI) or make other requests related to their privacy. |
N/A |
