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Individual Forms and Medicare Products  

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 Adobe. 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.


Individual Products
Applications and/or Miscellaneous Change Forms Form # Revision Date
Non-Underwritten Changes Miscellaneous Change Form 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 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. (69 KB)
 IND-MCF-Non-UW-1 06/07
Underwritten Changes Miscellaneous Change Form 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 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. (108 KB)
 IND-MCF-UW-1 06/07
BlueEdge Individual HSA Application/Miscellaneous Change Form (76 KB)
 BLUE EDGE-IND-HSA-APP/MCF-2 04/07
BlueEdge Individual HSA Special Offer Application This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. (58 KB) BLUE EDGE-IND-HSA-APP(SO) 05/06
Application/Miscellaneous Change Form for Foundation Hospital Care (73 kb) PPO-IN HOSPITAL-APP/MCF 04/07
MSA Blue Application/Miscellaneous Change Form (75 KB) IND-CMM-APP/MCF 01/07
PPO Select Basic Application (88 KB) PPO-IND-CCHBP-App.(B)-2 04/07
PPO Select Basic Miscellaneous Change Form
 PPO-IND-CCHBP-MCF(B)-2 01/07
PPO Select Value Care Application/Miscellaneous Change Form (175 KB) PPO-IND-VALUE-APP/MCF-1 04/07
PPO Select Value Care (Formulario de cambios de informacion de la solicitud/general para cobertura individual) This is the Spanish version of the PPO Select Value Care Application/Miscellaneous Change Form. (175 KB) FORMULARIO NRO.PPO-IND-VALUE-APP/MCF-1 04/07
SelecTEMP PPO Temporary Individual Coverage Application (76 KB) PPO-STM-3-APP 11/07
Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) (69 KB) IND-APP/MCF-1 04/07
Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application.
(62 KB)		 IND-APP(SO) 02/06
Solicitud/Formulario de cambios miscelaneos This is the Spanish version of the Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) IND-APP/MCF-1 01/06
Outline of Coverage and Patient Protection Act Disclosure Statements Form # Revision Date
BlueEdge Individual HSA Outline of Coverage (112 KB) PPO-BLUEEDGE-INDL-HSA-OLC-3 01/08
BlueEdge Individual HSA Patient Protection Act Disclosure Statement (108 KB) PPO-BLUEEDGE-INDL-HSA-PPA-3 01/08
Foundation Hospital Care Outline of Coverage (111 kb) PPO-IN HOSPITAL-OLC-1 01/08
Foundation Hospital Care Patient Protection Act Disclosure Statement (93 kb) PPO-IN HOSPITAL-PPA-1 01/08
PPO Select Basic Outline of Coverage (97 KB) PPO-CCHBP-OC-2 01/08
PPO Select Basic Patient Protection Act Disclosure Statement (93 KB) PPO-CCHBP-PPA-2 01/08
PPO Select Value Care Outline of Coverage (97 KB) PPO-IND-VALUE-OLC-2 01/08
PPO Select Value Care Patient Protection Act Disclosure Statement (100 KB) PPO-IND-VALUE-PPA-2 01/08
SelecTEMP PPO Outline of Coverage (312 KB) PPO-STM-3-OLC 01/06
SelecTEMP PPO Patient Protection Act Disclosure Statement (131 KB) PPO-STM-3-PPA 01/06
PPO Select Choice Outline of Coverage (Series III) (100 KB) PPO-SELCHOICE-3-OLC-2 01/08
PPO Select Choice Patient Protection Act Disclosure Statement (Series III) (102 KB) PPO-SELCHOICE-3-PPA-3 01/08
PPO Select Saver Outline of Coverage (Series III) (100 KB) PPO-SELSAVER-3-OLC-2 01/08
PPO Select Saver Patient Protection Act Disclosure Statement (Series III) (107 KB) PPO-SELSAVER-3-PPA-2 01/08
Select Blue Advantage Outline of Coverage (Series III) (107 KB) PPO-SELBLU-ADV-3-OLC-2 01/08
Select Blue Advantage Patient Protection Act Disclosure Statement (Series III) (109 KB) PPO-SELBLUE-ADV-3-PPA-2 01/08
General Miscellaneous Forms Form # Revision Date
Automatic Premium Payment Authorization Agreement Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. (38 KB) 8708.558.1007 10/07
Acuerdo de autorizacion para el pago de prima automaticoThis 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. (37 KB) 49218.1007 10/07
Blue HealthCare Bank (BHB) Sales Pack The BHB Sales Pack includes information on the following: About Health Savings Accounts – HSAs; Enrollment Instructions; Interest Rates & Fee Schedule; HSA Application; HSA Deposit Account Agreement and Privacy Policy & Practices. (6.39 MB) N/A 08/08
Blue HealthCare Bank (BHB) Producer Instructions/
Enrollment Form (2.30 MB)		 N/A 08/08
List Bill Agreement Includes information on how to establish a new list bill, the List Bill Agreement and Enrollment Form, and how to maintain a list bill. 4761.000.1106 11/06
Producer Supply Order Form Use this form to order sales materials including enrollment packets, rate guides and provider indexes. (392 KB) 8706.807-0708 07/08
Continuation of Coverage Request Form Use this form to continue existing coverage for dependents when membership is affected by divorce, death, or other qualifying events. (17 KB) 47133.1206 12/06
Series III Comparison Chart (143 KB) 47637.0407 04/07
Texas Special Offer and Transfer Guide (20 KB) N/A 08/08
Hallmark Web Site Rate Action Enhancements Instructions (1.3 MB) N/A 06/07
Multiple Dependent Applications Instructions (128 KB) N/A 05/08
Mail Order Form - Prime Mail Pharmacy (137 KB) 40690-1005 10/05
Prescription Reimbursement Claim Form (146 KB) 40959-704 07/04
Request for Underwriting Opinion Form (219 KB) N/A 08/07
Standard Authorization to Use or Disclose Protected Health Information (PHI) N/A 09/07
Dental Miscellaneous Forms Form # Revision Date
Dental Supply Order Form (21 kb)
 N/A 05/04
Dental Indemnity USA Monthly Premium Rate Guide (19 kb) N/A 04/04
Dental Indemnity USA Contract (256 kb)
 IND-DEN-2 06/07
Dental Indemnity USA Outline of Coverage (108 kb)
 OC-IND-DEN-2 04/07
Scheduled Benefit Plan - Region II (25 kb)
 TXGRGNII 04/03
Scheduled Benefit Plan - Region IV (22 kb)
 TXGRGNIV 04/03

Medicare Products

Thank you for your interest in Blue Medicare PPO. Please remember that before a producer can market Blue MedicareRx and/or Blue Medicare PPO (including ordering and/or downloading marketing materials), they must complete our training and certification/recertification program.

To access this course, please send an email to Broker_Admin_Individual@bcbstx.com to request additional information on how to complete the certification process.

To access additional marketing materials, please login to Blue Access for Producers.

Form Name Form # Revision Date
Blue MedicareRx (Part D)
Authorization to Disclose PHI - Available Soon PDP.PHI
Enrollment Form S5715_ENR_TMP_ ENRFRM08  
Plan Change Form S5715_BEN_TMP_PLNCHGFRM  
Product Summary S5715_MRK_TX_TMP_PRMPLCMT  
Summary of Benefits S5715_BEN_TMP_BNFTSMRY08  
ACH Form S5715-ENR-TXACH CMS  
Walgreen's Mail Order Form S5715-BEN-TXWebRxMailOrder  
Order and Print Blue MedicareRx Marketing Materials and Sales Kits N/A  
Medicare Supplement 
Medicare Supplement Rate Card (55 KB)
 30121.0108TX 11/08
Medicare Supplement Product Guide(67 KB)
 30119.0307TX 03/07
Medicare Supplement Combo Mailer (105 KB)
 30087.0108TX 11/08
Medicare Supplement Outline of Coverage (122 KB)
 UWMSP - OC (A,D,F,K&L) - 1 11/08
Medicare Supplement Replacement Notice (109 KB)
 MSP-REPLNOT – 2 (AGT) 07/04
Supply Requisition Form (52 KB)
 30129.0408TX  04/08
Medicare Supplement Application(92 KB)
 UWMSP – APP – 3- P 08/06
Medicare Supplement Sales Pack(703 KB) 30030.0108TX
 11/08
Protected Health Information (PHI) Authorization Form(75 KB) DTX149 03/03
Blue MedicarePPO 
Enrollment Form H3208_H4531_ENR_TMP_ENRFRM08  
Plan Change Form H3208_H4531_BEN_TMP_PLNCHGFRM  
Summary of Benefits H3208_H4531_MRK_TMP_BNFTSMRY08  
Auto Payment (ACH) Form H4531_ENR_ACHFORM  

 
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