Individual Plans: Information and Forms
Get the most from your 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.
Individual Health Insurance Products —
Applications and Forms
| Form Name and Description | Form # | Revision Date |
|---|---|---|
Series IV Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Save)  (90 kB) |
to IND-APP/MCF-3REV | 01/2011 |
| BlueEdgeSM Individual HSA Application/Miscellaneous Change Form (87 kB) |
BLUE EDGE IND-HSA-APP/MCF-5REV | 01/2011 |
| SelecTEMP® PPO Temporary Individual Coverage Application (34 kB) |
PPO-STM-3-App-3 | 08/2012 |
| Non-Underwritten Changes Miscellaneous Change Form (78 kB) This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select®, PPO Select Advantage and Select 2000) and non-Series III and Series IV Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits. |
IND-MCF-Non-UW-3 | 01/2011 |
| Underwritten Changes Miscellaneous Change Form (110 kB) This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III and Series IV Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits. |
IND-MCF-UW-3REV | 01/2011 |
| BlueEdge HSA Outline of Coverage (141kb) |
PPO-BLUEEDGE-INDL-HSA-3-OLC | 03/2012 |
| BlueEdge Individual HSA Special Offer Application (85 kB) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. |
BLUE EDGE-IND-HSA-APP(SO)-3REV | 01/2011 |
| Foundation Hospital Care Miscellaneous Change Form (97 kB) |
PPO-INHOSPITAL-APP/MCF-2REV | 01/2011 |
| MSA Blue Application/Miscellaneous Change Form (117 kB) |
IND-CMM-APP/MCF-3REV | 01/2011 |
| PPO Select Basic Miscellaneous Change Form (79 kB) |
PPO-IND-CCHBP-MCF(B)-4REV | 01/2011 |
| PPO Select Value® CareSM Miscellaneous Change Form (109 kB) |
PPO-IND-VALUE-APP/MCF-3REV | 01/2011 |
| SelecTEMP PPO Outline of Coverage (312 kB) |
PPO-STM-3-OLC-2 | 01/2010 |
| PPO Select Choice Outline of Coverage (Series V) (142kb) |
PPO-SELCHOICE-5-OLC | 03/2012 |
| PPO Select Saver Outline of Coverage (Series V) (193kb) |
PPO-SELSAVER-5-OLC | 03/2012 |
| Select Blue Advantage Outline of Coverage (Series V) (206kb) |
PPO-SELBLU-ADV-5-OLC | 03/2012 |
| Blue Pathway Outline of Coverage (104 kB) |
BLUE PATHWAY-OLC-1 | 09/2011 |
| Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) (85 kB) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. |
IND-APP(SO)-2REV | 01/2011 |
| Formulario de cambios varios/de solicitud (128 kB) This is the Spanish version of the Series IV Application/Miscellaneous Change Form |
IND-APP/MCF-3REV SP | 01/2011 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA (129 kB) This is the Spanish version of the PPO Select Choice Outline of Coverage. |
PPO-SELCHOICE-3-OLC-6 SP | 10/2010 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA (127 kB) This is the Spanish version of the PPO Select Saver Outline of Coverage. |
PPO-SELSAVER-3-OLC-5 SP | 10/2010 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA (76 kB) This is the Spanish version of the Select Blue Advantage Outline of Coverage. |
PPO-SELBLU-ADV-3-OLC-5 SP | 10/2010 |
General Miscellaneous Forms
| Form Name and Description | Form # | Revision Date |
|---|---|---|
| Automatic Premium Payment Authorization Agreement (95 kB) Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. |
51436.0711 | 07/2011 |
| Acuerdo de autorizacion para el pago de prima automatico (37 kB) This is the Spanish version of the Automatic Premium Payment Authorization Agreement. Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. |
49218.0409 | 04/2009 |
| Continuation of Coverage Request Form (17 kB) Use this form to continue existing coverage for dependents when membership is affected by divorce, death, or other qualifying events. |
47133.0109 | 01/2009 |
| Dental Provider Nomination Form (53 kB) Use this form to nominate a dental provider (dentist) to be in our network. |
N/A | 08/2010 |
| PrimeMail New Prescription Order Form (237 kB) 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. |
3208TXNEW | 12/2010 |
| PrimeMail Refill Prescription Order Form (360 kB) Members with BCBSTX prescription drug coverage can use this form to mail order refills for prescribed maintenance medication. |
3208TXREFILL | 12/2010 |
| Medical Claim Form (18 kB) |
1081.000.901 | 09/2001 |
| Medical Claim Form - Spanish (72 kB) |
1081.000.901 SP | 09/2001 |
| Prescription Drug Claim Form (for Group Plan members) (347 kB) 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. |
3272TX | 01/2012 |
| Prescription Drug Claim Form (for Individual Plan members) (218 kB) 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. |
3272TXIND | 01/2013 |
| Standard Authorization Form to Use or Disclose Protected Health Information (PHI) (114 kB) This form should be used only by members who have an Individual health insurance policy. |
SAF-TX | 01/2012 |
