Forms
If you need assistance with completing any of the following forms, please contact Blue Cross and Blue Shield of Texas (BCBSTX) Customer Service at (800) 252-8039.
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| Form | Description/Comments |
|---|---|
BCBSTX Medical Claim Form  (77 KB) |
File a claim for reimbursement for medical services. |
|
Group Benefits Program (GBP) Supplemental Information Forms: |
Use this form to choose your primary care physician (PCP). Your selection will be effective the day you call BCBSTX Customer Service or the date you sign your form. New employees: If you are in your health coverage waiting period (also called "90-day waiting period"), please do not send your GBP Supplemental Form more than 30 days before your health coverage becomes effective. |
| Standard Authorization Form and other HIPAA Privacy Forms |
Under the HIPAA Privacy Rule, an individual may authorize release of his or her protected health information (PHI) to a specific person. You must send a completed authorization form for BCBSTX to disclose PHI. |
| Transitional Benefits Request Form (49 KB) |
If your provider is leaving the network, or if you are new to HealthSelect and wish to continue receiving medical care from your non-network provider, you may be eligible for transitional benefits. Find out more about transitional benefits. |
| BlueCard International Claim Form |
When you or a covered dependent receive medical care outside the U.S. and need to file a claim, use the BlueCard Worldwide claim form. BlueCard Worldwide will translate your bills into English as well as convert the currency to U.S. Dollars for the dates of service when the medical care was received. |
| Prescription Drug Reimbursement Form (211 KB) Prescription Drug Mail-Order Form (1.17 MB) |
Caremark is Your Prescription Drug Administrator These claim forms should be used when filing for reimbursement for a prescription drug or when using the mail-order program for services rendered on or after September 1, 2008. If you need assistance in completing your prescription drug forms, call Caremark Customer Service at (888) 886-8490. |
| Medical Support Order Dependent Address Form (225 KB) |
Complete this form and send to: BCBSTX |
