Individual Forms

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Texas. To access more product information and sales resources, please log in to Blue Access for Producers.

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Stock # / Date	Enrollment Forms and Change Forms	Texas Form #
41745.0111	Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver)	IND-APP/MCF-3REV
41745.0111	Series V Application/Miscellaneous Change Form (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) - Spanish Version	IND-APP/MCF-3REV SP
42352.0111	Series V Special Offer Application (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver)  This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application	IND-APP(SO)-2REV
51164.0111	BlueEdge Individual HSA Application/Miscellaneous Change Form	BLUE EDGE IND-HSA-APP/MCF-5REV
51165.0111	BlueEdge Individual HSA Special Offer Application  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
42780.0812	SelecTEMP PPO Temporary Individual Coverage Application	PPO-STM-3-APP-3
42320.0111	Foundation Hospital Care Miscellaneous Change Form	PPO-INHOSPITAL-APP/MCF-2REV
42684.0111	PPO Select Value Care Miscellaneous Change Form	PPO-IND-VALUE-APP/MCF-3REV
41694.0111	PPO Select Basic Miscellaneous Change Form	PPO-IND-CCHBP-MCF(B)-4REV
43954.0111	MSA Blue Application/Miscellaneous Change Form	IND-CMM-APP/MCF-3REV
43971.0111	Non-Underwritten Changes Miscellaneous Change Form  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, IV, and V 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
43969.0111	Underwritten Changes Miscellaneous Change Form  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, IV, and V 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
Stock # / Date	Outlines of Coverage and Patient Protection Act Disclosure Statements	Texas Form #
55227.0412	PPO Select Choice Outline of Coverage (Series V)	PPO-SELCHOICE-5-OLC-1
55247.0412 SP	PPO Select Choice Outline of Coverage (Series V) - Spanish Version	PPO-SELCHOICE-5-OLC-1 SP
55228.0412	PPO Select Choice Patient Protection Act Disclosure Statement (Series V)	PPO-SELCHOICE-5-DS-1
55231.0412	PPO Select Saver Outline of Coverage (Series V)	PPO-SELSAVER-5-OLC-1
55231.0412 SP	PPO Select Saver Outline of Coverage (Series V) - Spanish Version	PPO-SELSAVER-5-OLC-1 SP
55232.0412	PPO Select Saver Patient Protection Act Disclosure Statement (Series V)	PPO-SELSAVER-5-DS-1
55235.0412	Select Blue Advantage Outline of Coverage (Series V)	PPO-SELBLUE-ADV-5-OLC-1
55235.0412 SP	Select Blue Advantage Outline of Coverage (Series V) - Spanish Version	PPO-SELBLUE-ADV-5-OLC-1 SP
55236.0412	Select Blue Advantage Patient Protection Act Disclosure Statement (Series V)	PPO-SELBLUE-ADV-5-DS-1
55239.0113	BlueEdge Individual HSA Outline of Coverage	PPO-BLUEEDGE-INDL-HSA-3-OLC-2
55239.0412 SP	BlueEdge Individual HSA Outline of Coverage - Spanish Version	PPO-BLUEEDGE-INDL-HSA-3-OLC-1 SP
55240.0412	BlueEdge Individual HSA Patient Protection Act Disclosure Statement	PPO-BLUEEDGE-INDL-HSA-3-DS-1
42339.0113	SelecTEMP PPO Outline of Coverage	PPO-STM-3-OLC-3
42340.0110	SelecTEMP PPO Patient Protection Act Disclosure Statement	PPO-STM-3-PPA-1
54504.0911	Blue Pathway Outline of Coverage	BLUE PATHWAY-OLC-1
Stock # / Date	Claim Forms and Order Forms	Texas Form #
40959.0113	Prescription Drug Claim Form  Members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. The original pharmacy receipt must be submitted with the completed form to Prime Therapeutics, the pharmacy benefits manager.	3272TXIND
1081.000.901	Medical Claim Form  Members should use this form to request reimbursement of health services not already filed by their doctor or hospital.	N/A
1081.000.901 SP	Medical Claim Form - Spanish Version  Members should use this form to request reimbursement of health services not already filed by their doctor or hospital.	N/A
N-12-420	BlueCard Worldwide® International Claim Form  Members should use this form to request reimbursement for out-of-network services received when traveling internationally (outside of U.S.).	N/A
N/A	PrimeMail New Prescription Order Form  Members with 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 the prescribing doctor.	3208TXNEW.1210
N/A	PrimeMail Refill Prescription Order Form  Members with prescription drug coverage can use this form to mail order refills for prescribed maintenance medication.	3208TXREFILL.1210
Stock # / Date	Miscellaneous Forms	Texas Form #
51436.0711	Automatic Premium Payment Authorization Agreement	N/A
49218.0409	Automatic Premium Payment Authorization Agreement - Spanish Version	N/A
47133.0109	Continuation of Coverage Request Form	N/A
51178.0109	List Bill Agreement	N/A
N/A	Producer of Record Transfer Form	N/A
N/A	Standard Authorization Form and other HIPAA Privacy Forms	N/A
Stock # / Date	Dental Plan Information	Texas Form #
40110.404	Dental Indemnity USA Monthly Premium Rate Guide	N/A
0009.374-0908	Dental Indemnity USA Outline of Coverage	IND-DEN-2-OLC-1
N/A	Dental Scheduled Benefit Plan - Region II	TXGRGNII
N/A	Dental Scheduled Benefit Plan - Region IV	TXGRGNIV
Stock # / Date	Other Plan Information	Texas Form #
53398.0312	Blue Pathway Sales Flier	N/A
43378.0413	Plan Comparison Chart	N/A
56545.0113	Plan Comparison Chart - Spanish Version	N/A
50400.0113	Product Guide Brochure	N/A
54537.0113	Product Guide Brochure - Spanish Version	N/A
46086.0113	SelecTEMP PPO Flier	N/A