Enrollment Application/Change Form - English (Interactive PDF - 501K)
You can select coverage and type your enrollment information for TRS-ActiveCare by downloading this interactive application/change form. Once you've entered your information, print the application, sign and date it, and submit it to your district's Benefits Administrator. (The application cannot be submitted online or saved to a disk or hard drive.) Be sure to print an extra copy for your records.
Solicitud de Inscripción y Formulario de Cambio (Interactive PDF - 408K)
Solicitud en Español Provista A Través del Internet. Usted puede elegir una cobertura y proveer su información de solicitud para TRS-ActiveCare trasladando información de este formulario de solicitud/cambio. Una vez que haya provisto su información, imprima la solicitud, fírmela, póngale la fecha y envíela al Administrador de Beneficios de su distrito. (La solicitud no podrá ser enviada por Internet o guardada en un diskette o disco duro.) Asegúrese de imprimir una copia extra para su archivo personal.
Transitional Benefits Request/Provider Release of Information
If you or a covered dependent will be undergoing a course of medical treatment at the time of joining TRS-ActiveCare and the physician is not in the network, ongoing care with the current doctor may be requested for a period of time. To receive the highest level of benefits, a Transitional Benefits form must be completed and approved. Instructions for submitting the request are on the form. Note: This form is not required if the physician is in the network.
Dependent Child's Statement of Disability
If you are applying for coverage for a dependent over age 25, this form must be completed and submitted with your enrollment application for TRS-ActiveCare.
Application to Split Premium
If a husband and wife work for different participating entities and wish to pool their district and state funds to use toward the cost of TRS-ActiveCare coverage, each employee and their Benefits Administrators must complete the Application to Split Premium and submit the form with the Enrollment application and Change Form. For the husband and wife who choose this option, the cost of coverage will be split between and billed to the two employers.
Claim Form
Blue Cross and Blue Shield of Texas plan participants who have PPO coverage through TRS-ActiveCare can use this form to file claims for reimbursement - including non-network medical claims - that are not filed by their providers.
