Downloadable Forms for Mid-Market Group Products (Groups of 51-150)

Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSTX policy

Group Enrollment Application/Change Form – Spanish

2024 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/24 and after

2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/24 and after

2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/23 and after

Employment Group Information (EGI) Form

Affidavit of Domestic Partnership

Affidavit of Domestic Partnership – Spanish

COBRA Continuation of Coverage Application & Social Security Disability Form

COBRA Initial Notice Requirements

Dependent Addition and Change Form for Court-Mandated Health Coverage

Dependent State Continuation of Coverage Form

Dependent Student Medical Leave Certification Form

Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSTX (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).

HSA/FSA Employer Setup Form – HealthEquity^® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity.

HSA Employer Setup Form – HSA Bank^® – Submit an electronic copy of this form if you wish to open accounts for your employees at HSA Bank.

HSA Employer Setup Form – Benefit Wallet^® – Submit an electronic copy of this form if you wish to open accounts for your employees at Benefit Wallet.

Average Employee Count (AEC) Form

Student Certification Form

Texas Nine (9) Month State Continuation of Insurance Application Form

Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA) 

Dental Claim Form – Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.

Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.

Medical Claim Form (Domestic) – Spanish

Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.

Medical Claim Form (International) – Spanish

Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSTX can use this claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. On page 3 of the form, members can get more info on how they may get in-network credit for a cash payment made to an out-of-network pharmacy. They must submit the pharmacy counter receipt with the completed form. Cash register receipts for OTC COVID-19 test kits may not be accepted. Not all plans cover OTC COVID-19 home test kits. If the member’s plan does not cover, they will not be reimbursed.

Prescription Drug Claim Form (Prime Therapeutics) – Spanish

Prescription Drug Mail-Order Form (Express Scripts) – Members with prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. They need to mail the completed form to the address provided on the form, and include the original prescription signed by their doctor.

Prescription Drug Mail-Order Form (Express Scripts) – Spanish

Annual MSP Employer Acknowledgement Form (EAF) with Instructions

Information Regarding MSP Statute

MSP Fact Sheet

Standard Authorization Form and other HIPAA Privacy Forms

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