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Employer Offered Coverage Information and Forms

Get the most from your Employer Offered health insurance coverage by using these helpful forms and documents to make plan changes, add features and learn about other important ways to help manage your account.

These forms are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site. 

Note: If these downloadable PDF forms are altered in any way, they will not be processed by Blue Cross and Blue Shield of Texas (BCBSTX).

HMO Members Rights and Responsibilities

Employer Offered Coverage Forms to Return to HR

Photocopy and return these completed forms to your employer's human resource department. Keep a copy for your records.

Stock # / Date

Downloadable Forms

Texas Form #

54521.0913

2014 Enrollment Application/Change Form  

For members of new accounts effective on and after Jan. 1, 2014 and for members of existing accounts that have reached their 2014 renewal dates.

EA/CF 0913

54521.1012

2013 Enrollment Application/Change Form 

For members of accounts that enroll as new groups or renew before Jan. 1, 2014.

EA/CF 1012

54761.1212

2013 Enrollment Application/Change Form - Spanish 

Same instructions as stated above for existing and new group members.

EA/CF 1212 SP

R2/07 X6053

Change Life Beneficiary 

Members who have life coverage through Group Life and Health/Dearborn National can use this form to change beneficiaries on their life policies.

N/A

43942.1106

Dependent State Continuation of Coverage 

Existing BCBSTX group members may request a continuation of coverage of their current benefits for up to 36 months if coverage is loss due to divorce, death or retirement of the employee.

StateContDep06

2487.000-202

Disabled Dependent Certification Form 

BCBSTX members use this form if the dependent is incapable of self-support because of mental or physical impairment.

N/A

54545.0611

Student Certification Form 

BCBSTX members can use this form to certify and report a dependent as a student.

N/A

Employer Offered Coverage Forms to Return to BCBSTX

Photocopy and return these completed forms to BCBSTX. Keep a copy for your records.

Stock # / Date

Downloadable Forms

Texas Form #

1081.000-901

Medical Claim Form 

BCBSTX members who have PPO or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers.

N/A

1081.000-901 SP

Medical Claim Form - Spanish 

BCBSTX members who have PPO or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers.

N/A

8708.995-102

HMO Blue® Texas Medical Claim Form 

HMO Blue® Texas members can use this form to file claims for reimbursement that are not filed by their providers.

MBRCLM102

N/A

Away From Home Care Guest Membership Application (for HMO members) 

HMO members can use this form to apply for guest membership at a Host HMO when residing outside their home plan service area for 90+ consecutive days. Please read and follow the instructions on the form.

N/A

55352.0112

Dental Claim Form 

BCBSTX members with dental coverage can use this form to file dental claims for reimbursement that are not filed by their providers

N/A

N/A

Dental Provider Nomination Form 

Please mail or fax this completed form to nominate a dental provider for inclusion in the dental provider network.

N/A

N/A

Standard Authorization Form and other HIPAA Privacy Forms 

Members can provide authorization for BCBSTX to share Protected Health Information (PHI) or make other requests related to their privacy.

N/A

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