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Individual Plans: Information and Forms

Get the most from your 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.

 

Individual Health Insurance Products —
Applications and Forms

 


Form Name and DescriptionForm #Revision Date
2014 Texas Individual Product Under 65 Off Exchange Medical Application or Change in Coverage - English  (203 kB) 57330.0313 01/2014
2014 Texas Individual Product Under 65 Off Exchange Medical Application or Change in Coverage - Spanish  (337 kB) 725600.0313 01/2014
Series IV Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Save)  (90 kB) to IND-APP/MCF-3REV 01/2011
BlueEdgeSM Individual HSA Application/Miscellaneous Change Form  (87 kB) BLUE EDGE IND-HSA-APP/MCF-5REV 01/2011
SelecTEMP® PPO Temporary Individual Coverage Application  (34 kB) PPO-STM-3-App-3 08/2012
Non-Underwritten Changes Miscellaneous Change Form (78 kB)
This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select®, PPO Select Advantage and Select 2000) and non-Series III and Series IV Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits.
IND-MCF-Non-UW-3 01/2011
Underwritten Changes Miscellaneous Change Form (110 kB)
This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III and Series IV Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits.
IND-MCF-UW-3REV 01/2011
BlueEdge HSA Outline of Coverage  (141kb) PPO-BLUEEDGE-INDL-HSA-3-OLC 03/2012
BlueEdge Individual HSA Special Offer Application (85 kB)
This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application.
BLUE EDGE-IND-HSA-APP(SO)-3REV 01/2011
Foundation Hospital Care Miscellaneous Change Form  (97 kB) PPO-INHOSPITAL-APP/MCF-2REV 01/2011
MSA Blue Application/Miscellaneous Change Form  (117 kB) IND-CMM-APP/MCF-3REV 01/2011
PPO Select Basic Miscellaneous Change Form  (79 kB) PPO-IND-CCHBP-MCF(B)-4REV 01/2011
PPO Select Value® CareSM Miscellaneous Change Form  (109 kB) PPO-IND-VALUE-APP/MCF-3REV 01/2011
SelecTEMP PPO Outline of Coverage  (312 kB) PPO-STM-3-OLC-2 01/2010
PPO Select Choice Outline of Coverage (Series V)  (142kb) PPO-SELCHOICE-5-OLC 03/2012
PPO Select Saver Outline of Coverage (Series V)  (193kb) PPO-SELSAVER-5-OLC 03/2012
Select Blue Advantage Outline of Coverage (Series V)  (206kb) PPO-SELBLU-ADV-5-OLC 03/2012
Blue Pathway Outline of Coverage  (104 kB) BLUE PATHWAY-OLC-1 09/2011
Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) (85 kB)
This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application.
IND-APP(SO)-2REV 01/2011
Formulario de cambios varios/de solicitud (128 kB)
This is the Spanish version of the Series IV Application/Miscellaneous Change Form
IND-APP/MCF-3REV SP 01/2011
PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA  (129 kB)
This is the Spanish version of the PPO Select Choice Outline of Coverage.
PPO-SELCHOICE-3-OLC-6 SP 10/2010
PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA  (127 kB)
This is the Spanish version of the PPO Select Saver Outline of Coverage.
PPO-SELSAVER-3-OLC-5 SP 10/2010
Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA  (76 kB)
This is the Spanish version of the Select Blue Advantage Outline of Coverage.
PPO-SELBLU-ADV-3-OLC-5 SP 10/2010


General Miscellaneous Forms


Form Name and DescriptionForm #Revision Date
Automatic Premium Payment Authorization Agreement (95 kB)
Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts.
51436.0713 07/2013
Acuerdo de autorizacion para el pago de prima automatico (37 kB)
This is the Spanish version of the Automatic Premium Payment Authorization Agreement. Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts.
726665.0114 01/2014
Continuation of Coverage Request Form (17 kB)
Use this form to continue existing coverage for dependents when membership is affected by divorce, death, or other qualifying events.
47133.0109 01/2009
Dental Provider Nomination Form (53 kB)
Use this form to nominate a dental provider (dentist) to be in our network.
N/A 08/2010
PrimeMail New Prescription Order Form  (237 kB)
Members with BCBSTX prescription drug coverage can use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail, and include the original prescription signed by your doctor.
3208TXNEW 12/2010
PrimeMail Refill Prescription Order Form  (360 kB)
Members with BCBSTX prescription drug coverage can use this form to mail order refills for prescribed maintenance medication.
3208TXREFILL 12/2010
Medical Claim Form  (18 kB) 1081.000.901 09/2001
Medical Claim Form - Spanish (72 kB) 1081.000.901 SP 09/2001
Prescription Drug Claim Form (for Group Plan members) (347 kB)
BCBSTX members with pharmacy benefits through an employer group insurance plan can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSTX pharmacy benefits manager.
3272TX 01/2012
Prescription Drug Claim Form (for Individual Plan members) (218 kB)
BCBSTX members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. Members must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSTX pharmacy benefits manager.
3272TXIND 01/2013
Standard Authorization Form to Use or Disclose Protected Health Information (PHI)  (114 kB)
This form should be used only by members who have an Individual health insurance policy.
SAF-TX 01/2012

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