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 
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Be sure to keep a copy for your records.
Individual Products |
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| 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 (90 KB) |
BLUE EDGE-IND-HSA-APP/MCF-3 | 08/09 |
| 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. (69 KB) |
BLUE EDGE-IND-HSA-APP(SO)-1 | 08/09 |
| 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 (34 KB) |
PPO-STM-3-APP-2 | 04/09 |
| 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 | 04/07 |
| Outline of Coverage and Patient Protection Act Disclosure Statements | Form # | Revision Date |
| BlueEdge Individual HSA Outline of Coverage (215 KB) Use this form with policies effective prior to January 1, 2010. |
PPO-BLUEEDGE-INDL-HSA-OLC-6 | 08/09 |
| BlueEdge Individual HSA Outline of Coverage (215 KB) Use this form with policies effective January 1, 2010 or later. |
PPO-BLUEEDGE-INDL-HSA-OLC-6 | 01/10 |
| BlueEdge Individual HSA Patient Protection Act Disclosure Statement (243 KB) |
PPO-BLUEEDGE-INDL-HSA-PPA-5 | 01/10 |
| Foundation Hospital Care Outline of Coverage (111 kb) |
PPO-IN HOSPITAL-OLC-2 | 12/08 |
| Foundation Hospital Care Patient Protection Act Disclosure Statement (93 kb) |
PPO-IN HOSPITAL-PPA-2 | 01/10 |
| PPO Select Basic Outline of Coverage (97 KB) |
PPO-CCHBP-OC-3 | 12/08 |
| PPO Select Basic Patient Protection Act Disclosure Statement (93 KB) |
PPO-CCHBP-PPA-3 | 01/10 |
| PPO Select Value Care Outline of Coverage (97 KB) |
PPO-IND-VALUE-OLC-3 | 12/08 |
| 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-1 | 12/08 |
| 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-3 | 12/08 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Choice Outline of Coverage. (129 KB) |
PPO-CHOICE-3-OLC-2SP | 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-3 | 12/08 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Saver Outline of Coverage. (127 KB) |
PPO-SAVER-3-OLC-2SP | 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-3 | 12/08 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the Select Blue Advantage Outline of Coverage. (76 KB) |
PPO-SELBLUE-ADV-3-OLC-2SP | 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. (124 KB) |
51436.1209 | 12/09 |
| Acuerdo de autorizacion para el pago de prima automatico 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. (37 KB) |
49218.1007 | 10/07 |
| BlueEdge Individual HSA Sales Brochure (899 KB) |
47054.1009 | 10/09 |
| BlueEdge Individual HSA Amendment (Effective 1-1-10) (899 KB) |
51849.0110 | 01/10 |
| 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. |
51178.0109 | 01/09 |
| Producer Supply Order Form Use this form to order sales materials including enrollment packets, rate guides and provider indexes. (534 KB) |
8706.807-0110 | 01/10 |
| 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) |
47133.0109 | 01/09 |
| Series III Comparison Chart (143 KB) |
47637.0407 | 04/07 |
| Texas Special Offer and Transfer Guide (20 KB) |
N/A | 10/08 |
| 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 |
| Standard Authorization to Use or Disclose Protected Health Information (PHI) This form should be used only by members who have an Individual health insurance policy. |
N/A | 09/07 |
| Dental Miscellaneous Forms | Form # | Revision Date |
| Dental Supply Order Form (21 kb) |
40111-0809 | 08/09 |
| 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 (495 kb) |
IND-DEN-2 OLC-1 |
09/08 |
| 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 Rx (PDP). Please remember that before a producer can market Blue MedicareRx (PDP), order and/or download marketing materials, they must complete our training and certification/re-certification program .
| Medicare Supplement | Form # | Revision Date |
| Medicare Supplement Rate Card (88 KB) |
30121.0110TX | 01/10 |
| Medicare Supplement Product Guide (336 KB) |
31263.0110TX | 01/10 |
| Medicare Supplement Combo Mailer (312 KB) |
30087.0110TX | 01/10 |
| Medicare Supplement Outline of Coverage (140 KB) |
UWMSP-OC (A,D,F,G,K&L)-P | 01/10 |
| Medicare Supplement Replacement Notice (108 KB) |
MSP-REPLNOT – 2 (AGT) | 07/05 |
| Medicare Supply Requisition Form (15 KB) |
30129.0409 TX | 04/09 |
| Medicare Supplement Application (92 KB) |
UWMSP–APP–3-P-MED-SEL | 01/09 |
| Medicare Supplement Sales Pack (1.57 MB) |
MS-AGENT-SALESBK Rev 01/09 | 01/10 |
| Medicare Supplement Blue Extras Discount Program (132 KB) |
31259.0110 TX | 01/10 |
| Medicare Select Network Hospital Listing (260 KB) |
51180.0210 TX | 02/10 |
| Protected Health Information (PHI) Authorization Form (75 KB) |
N/A | 09/07 |
