Downloadable Forms

Please select one of the links below to view that form.

Form Name	Form Number	PDF Size
Coverage Change Termination Form		33 KB
Enrollment Application/Change Form	TDI#:  EA/CF 1011	549 KB
Enrollment Application/Change Form — Spanish	TDI#:  EA/CF 1011SP	554 KB
Medical Claim Form		18 KB
Medical Claim Form - Spanish Version		72 KB
Dental Claim Form		137 KB
HMO Blue® Texas Medical Claim Form	8708.995-102	19 KB
Mail Order Prescription Form	40690.1210	131 KB
Dependent Addition and Change Form for Court Ordered Dependents	TDI#:  GDA-CMHC-02	25 KB
Dependent Child Statement of Disability	TDI#:  DISABILITY02	19 KB
Small Employer Benefit Program Application (05/11)  Immediately replaces SERA28R for new groups with effective dates on and after Sept. 1, 2011. NOTE: if you have already obtained a group signature on SERA28R, it will be accepted.	TDI# TXBPASG1	499 KB
Small Employer Benefit Program Application (Application for Amendment) (07/11)  Immediately replaces SERA28A for groups with renewal dates on and after Sept. 1, 2011. NOTE: if you have already obtained a group signature on SERA28A, it will be accepted.	TDI# TXBPASG1A	286 KB
COBRA Initial Notice Form #0009.443 (rev 08/04)   Employers are required to provide a COBRA Initial Notice when employees or their dependent spouses first become covered by a group health insurance plan subject to COBRA. In an effort to assist employer groups, HCSC has incorporated this notice into the Certificates of Coverage and Benefit Booklet. Although HCSC has taken this extra step, it is the employer group’s responsibility to make this notice available to each covered employee and to the employee’s spouse (if covered under the health insurance plan) not later than the earlier of: Either 90 days from the date on which the covered employee or spouse first becomes covered under the plan; or if later, the date on which the plan first becomes subject to the continuation coverage requirements; or the date on which the administrator is required to furnish an election notice to the employee or to his or her spouse or dependent.		104 KB
Continuation of Coverage (COBRA) & COBRA Disability Form #COBRA06, 05253.1106 (rev 11/06)  Application for Group Benefit Officers to request continued coverage for employee due to employee's reduction in work hours, retirement, termination, etc. Application includes two sections; Application For COBRA First Qualifying Event and Application for COBRA Second Qualifying Event.		106 KB
Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA)  This application is for members whose 18-month COBRA Continuation Coverage has ended, and who are eligible for an additional six (6) months of Continuation Coverage under Texas law. Use this form if your group administers its own COBRA Continuation Coverage. If BCBSTX is your group's COBRA Services administrator, please call 888-541-7107. If an outside Third-Party-Administrator (TPA) administers your continuation coverage, please contact your TPA.	#53780.1011	127 KB
Texas Nine (9) Month State Continuaton of Insurance Application Form  This application is for members who are not eligible for COBRA, but have the option to elect nine (9) months of Continuation Coverage under Texas law. Use this form if your group administers its own Texas State Continuation of Coverage. If BCBSTX is your group's Texas State Continuation of Coverage administrator, please call 888-541-7107.	#53594.1011	127 KB
Dependent State Continuation Form #StateContDep06, 43942.1106 (rev 11/06)   Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage for up to 36 months from loss of coverage due to divorce, death or retirement of the employee.		38 KB

HR Forms

Form Name	Form Number	PDF Size
Change Life/ Beneficiary		213 KB
Solicitud De Inscripcion De Grupo/ Cambio	TDI#:  EE/CHG3 1003SP	546 KB
Student Dependent Certification (rev 01/10)		48 KB
Student Dependent Medical Leave Form		36 KB

Medicare Secondary Payer Forms

Form Name	Form Number	PDF Size
Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form	TDI#:  21125.0111	124 KB
Information Regarding the Medicare as Secondary Payer Statute	TDI#:  21092.0609	297 KB

Under federal law, it is the employer's responsibility to inform its insurer or third-party administrator of proper employee counts for the purpose of determining payment priority between Medicare and another insurer. Employer size, not group health insurance plan size, is used in determining whether the group health insurance plan or Medicare is the primary payer. For more details please refer to the Instructions — Completing the Annual MSP Employer Acknowledgement Form. In the absence of employer-provided employee counts, the Center for Medicaid & Medicare Services (CMS) requires that the employer's group health insurance plan coverage be considered primary to Medicare. To comply with this requirement Blue Cross and Blue Shield of Texas requires employer groups to complete the Annual MSP Employer Acknowledgement Form on a yearly basis. Additional information regarding the MSP statute is available in the document titled Information Regarding the Medicare as Secondary Payer Statute.