Group Forms
For your convenience, we've put together the following downloadable forms. Acrobat Reader software will enable you to download these PDF files. If you currently don't have the software, you can get a free copy from the Adobe Systems Incorporated Web site
. You can also visit our section on how to download a PDF file for additional information.
Be sure to keep a copy for your records.
Group Products |
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| Form Name | Form # | Revision Date |
Census Import Template This MS Excel file can be used as a census import template in conjunction with eSales Tools group quoting available through Blue Access for Producers. Use the Help file on the Census page in eSales Tools for details on how to successfully import a census file.(16 KB, Excel) |
N/A | 10/09 |
| Change Life Beneficiary (30 KB) |
9025.000-500 | 05/00 |
| COBRA Initial Notice Requirements 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 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. |
0009.443 | 08/04 |
| Continuation of Coverage (COBRA) & COBRA Disability |
COBRA06, 05253.1106 | 11/06 |
| Dependent Addition and Change Form for Court Mandated Health Coverage |
2849.276 | 01/04 |
| Dependent State Continuation |
StateContDep06, 43942.1106 | 11/06 |
| Dental Claim Form |
6737.000-901 | 12/06 |
| Formulario de cambios de información/Solicitud de inscripción grupal |
EE/CHG5-SP 0807 | 08/07 |
| Group Administered 6 Mth Continuation Application Application for Group Benefit Officers to request an additional 6 months of coverage after COBRA has expired or as an initial request for continued coverage for smaller groups not subject to COBRA regulations. (106 KB) |
GroupAdmin06, 43936.1106 | 11/06 |
| Group Enrollment Application/Change Form |
EE/CHG5 0807 | 08/07 |
| HMO Blue® Texas Medical Claim Form |
8708.995-102 | 01/02 |
| Mail Order Prescription Form |
40690-704 | 07/04 |
| Medical Claim Form |
1081.000-901 | 09/01 |
| Medical Claim Form - Spanish Version |
1081.000-901 | 09/01 |
| Prescription Drug Reimbursement Claim Form (36 KB) |
40959-704 | 07/04 |
| Proxy Letter |
FC849 | 07/83 |
| RCI Utilizers Request Form |
N/A | 07/09 |
| Small Group Employer Application Small Group Employer Application Use immediately for quotes and new accounts effective 01.01.2010 and after. NOTE: In the event the authorized company official's signature has already been obtained, SERA26 will be accepted. |
SERA27 | 01/10 |
| Small Group Employer Application for Amendment (72 KB) Small Group Employer Application for Amendment For changes to new and existing accounts on 01.01.2010 and after. NOTE: In the event the authorized company official's signature has already been obtained, SERA26A will be accepted. |
SERA27A | 01/10 |
| Small Group Submission Checklist (64 KB) |
51362.1209 | 12/09 |
| Small Group Important Timelines |
52687.0110 | 01/10 |
| Student Dependent Certification This form is being revised. Members may call the number on the back of their identification cards to update or discuss dependents' student status. |
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| Student Dependent Medical Leave Form |
N/A | 09/09 |
| Texas Supplemental Employment Verification Form |
N/A | 09/09 |
| Tips for Submitting New Small Groups (388 KB) |
N/A | N/A |
Medicare Secondary Payer Forms |
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| Annual MSP Employer Acknowledgement Form |
21084.1009 | 10/09 |
| Instructions - Completing the Annual MSP Employer Acknowledgement Form |
21088-1009 | 10/09 |
| Information Regarding the Medicare as Secondary Payer |
21092-0609 | 06/09 |
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 plan size, is used in determining whether the group health 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 plan coverage be considered primary to Medicare. To comply with this requirement BCBSTX 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. |
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This MS Excel file can be used as a census import template in conjunction with eSales Tools group quoting available through Blue Access for Producers. Use the Help file on the Census page in eSales Tools for details on how to successfully import a census file.