Individual Forms and Medicare Products
For your convenience, we've put together the following downloadable forms. Acrobat Reader software will enable you to download these PDF files. If you currently don't have the software, you can get a free copy from Adobe 
. You can also visit our section on how to download a PDF file for additional information.
Individual Products
NOTE: The product information being displayed does not incorporate changes mandated by the Affordable Care Act of 2010 and are not reflective of the final benefits for products with an October 1, 2010, or later effective date.
| Applications and/or Miscellaneous Change Forms | Form # | Revision Date |
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 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. (78 KB) |
IND-MCF-Non-UW-2 | 09/2010 |
| 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 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. (110 KB) |
IND-MCF-UW-2 | 09/2010 |
| BlueEdge Individual HSA Application/Miscellaneous Change Form (104 KB) |
BLUE EDGE-IND-HSA-APP/MCF-4 | 09/2010 |
| 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. (85 KB) |
BLUE EDGE-IND-HSA-APP(SO)-2 | 09/2010 |
| Application/Miscellaneous Change Form for Foundation Hospital Care (97 kb) |
PPO-IN HOSPITAL-APP/MCF-1 | 09/2010 |
| MSA Blue Application/Miscellaneous Change Form (117 KB) |
IND-CMM-APP/MCF-2 | 09/2010 |
| PPO Select Basic Miscellaneous Change Form (97 KB) |
PPO-IND-CCHBP-MCF(B)-3 | 09/2010 |
| PPO Select Value Care Application/Miscellaneous Change Form (109 KB) |
PPO-IND-VALUE-APP/MCF-2 | 09/2010 |
| PPO Select Value Care (Formulario de cambios de informacion de la solicitud/general para cobertura individual) This is the Spanish version of the PPO Select Value Care Application/Miscellaneous Change Form. (175 KB) |
PPO-IND-VALUE-APP/MCF-1 | 04/2007 |
| SelecTEMP PPO Temporary Individual Coverage Application (34 KB) |
PPO-STM-3-APP-2 | 04/2009 |
| Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) (98 KB) |
IND-APP/MCF-2 | 09/2010 |
| Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. (85 KB) |
IND-APP(SO)-1 | 09/2010 |
| Solicitud/Formulario de cambios miscelaneos This is the Spanish version of the Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) |
IND-APP/MCF-1 | 04/2007 |
| Outline of Coverage and Patient Protection Act Disclosure Statements | Form # | Revision Date |
| Important Notice Regarding Your Benefits The information in the Outline of Coverage does not incorporate changes mandated by the Affordable Care Act of 2010 and is not reflective of the final benefits for products with an October 1, 2010, or later effective date. (215 KB) |
TX Ind ngf ooc | 07/2010 |
| BlueEdge Individual HSA Outline of Coverage (215 KB) |
PPO-BLUEEDGE-INDL-HSA-OLC-8 | 04/2010 |
| BlueEdge Individual HSA Patient Protection Act Disclosure Statement (243 KB) |
PPO-BLUEEDGE-INDL-HSA-PPA-7 | 04/2010 |
| SelecTEMP PPO Outline of Coverage (312 KB) |
PPO-STM-3-OLC-2 | 01/2010 |
| SelecTEMP PPO Patient Protection Act Disclosure Statement (131 KB) |
PPO-STM-3-PPA-1 | 01/2010 |
| PPO Select Choice Outline of Coverage (Series III) (100 KB) |
PPO-SELCHOICE-3-OLC-4 | 01/2010 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Choice Outline of Coverage. (129 KB) |
PPO-CHOICE-3-OLC-2SP | 01/2008 |
| PPO Select Choice Patient Protection Act Disclosure Statement (Series III) (102 KB) |
PPO-SELCHOICE-3-PPA-4 | 01/2010 |
| PPO Select Saver Outline of Coverage (Series III) (100 KB) |
PPO-SELSAVER-3-OLC-4 | 01/2010 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Saver Outline of Coverage. (127 KB) |
PPO-SAVER-3-OLC-2SP | 01/2008 |
| PPO Select Saver Patient Protection Act Disclosure Statement (Series III) (107 KB) |
PPO-SELSAVER-3-PPA-3 | 01/2010 |
| Select Blue Advantage Outline of Coverage (Series III) (107 KB) |
PPO-SELBLU-ADV-3-OLC-4 | 01/2010 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the Select Blue Advantage Outline of Coverage. (76 KB) |
PPO-SELBLUE-ADV-3-OLC-2SP | 01/2008 |
| Select Blue Advantage Patient Protection Act Disclosure Statement (Series III) (109 KB) |
PPO-SELBLUE-ADV-3-PPA-3 | 01/2010 |
| General Miscellaneous Forms | Form # | Revision Date |
Producer Commission Electronic Funds Transfer Form  Use this form to set up a new electronic funds transfer (EFT) payment program or to change your existing EFT payment program. The form can be mailed or faxed to the Broker Administration Department at Blue Cross and Blue Shield of Texas. Address and fax number are included in the form. (52 KB) |
N/A | 11/2009 |
| Automatic Premium Payment Authorization Agreement Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. (124 KB) |
51436.1209 | 12/2009 |
| Acuerdo de autorizacion para el pago de prima automatico 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. (37 KB) |
49218.0409 | 04/2009 |
| BlueEdge Individual HSA Sales Brochure (899 KB) |
47054.0110 | 01/2010 |
| BlueEdge Individual HSA Amendment (Effective 1-1-10) (899 KB) |
51849.0110 | 01/2010 |
| List Bill Agreement Includes information on how to establish a new list bill, the List Bill Agreement and Enrollment Form, and how to maintain a list bill. |
51178.0109 | 01/2009 |
| Producer Supply Order Form Use this form to order sales materials including enrollment packets, rate guides and provider indexes. (534 KB) |
8706.807-0710 | 07/2010 |
| Continuation of Coverage Request Form Use this form to continue existing coverage for dependents when membership is affected by divorce, death, or other qualifying events. (17 KB) |
47133.0109 | 01/2009 |
| Texas Special Offer and Transfer Guide (20 KB) |
N/A | 10/2008 |
| Multiple Dependent Applications Instructions (128 KB) |
N/A | 05/2008 |
| Mail Order Form - Prime Mail Pharmacy (137 KB) |
40690-1005 | 10/2005 |
| Prescription Reimbursement Claim Form (146 KB) |
40959-704 | 07/2004 |
| Standard Authorization to Use or Disclose Protected Health Information (PHI) This form should be used only by members who have an Individual health insurance policy. |
N/A | 09/2007 |
| Dental Miscellaneous Forms | Form # | Revision Date |
| Dental Supply Order Form (21 kb) |
40111-0809 | 08/2009 |
| Dental Indemnity USA Monthly Premium Rate Guide (19 kb) |
N/A | 04/2004 |
| Dental Indemnity USA Outline of Coverage (495 kb) |
IND-DEN-2 OLC-1 |
09/2008 |
| Dental Scheduled Benefit Plan - Region II (25 kb) |
TXGRGNII | 04/2003 |
| Dental Scheduled Benefit Plan - Region IV (22 kb) |
TXGRGNIV | 04/2003 |
Medicare Products
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