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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Individual Products
| Applications and/or Miscellaneous Change Forms | Form # | Revision Date |
| Series IV Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver) |
IND-APP/MCF-3REV | 01/2011 |
| BlueEdge Individual HSA Application/Miscellaneous Change Form |
BLUE EDGE IND-HSA-APP/MCF-5REV | 01/2011 |
| SelecTEMP PPO Temporary Individual Coverage Application |
PPO-STM-3-APP-2 | 05/2011 |
| Non-Underwritten Changes Miscellaneous Change Form |
IND-MCF-Non-UW-3 | 01/2011 |
| Underwritten Changes Miscellaneous Change Form |
IND-MCF-UW-3REV | 01/2011 |
| BlueEdge Individual HSA Special Offer Application |
BLUE EDGE-IND-HSA-APP(SO)-3REV | 01/2011 |
| Foundation Hospital Care Miscellaneous Change Form |
PPO-INHOSPITAL-APP/MCF-2REV | 01/2011 |
| MSA Blue Application/Miscellaneous Change Form |
IND-CMM-APP/MCF-3REV | 01/2011 |
| PPO Select Basic Miscellaneous Change Form |
PPO-IND-CCHBP-MCF(B)-4REV | 01/2011 |
| PPO Select Value Care Miscellaneous Change Form |
PPO-IND-VALUE-APP/MCF-3REV | 01/2011 |
| Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) (85 KB) |
IND-APP(SO)-2REV | 01/2011 |
| Formulario de cambios varios/de solicitud |
IND-APP/MCF-3REV SP | 01/2011 |
| Outline of Coverage and Patient Protection Act Disclosure Statements | Form # | Revision Date |
| BlueEdge Individual HSA Outline of Coverage |
PPO-BLUEEDGE-INDL-HSA-OLC-10 | 09/2011 |
| BlueEdge Individual HSA Patient Protection Act Disclosure Statement |
PPO-BLUEEDGE-INDL-HSA-PPA-8 | 10/2010 |
| SelecTEMP PPO Outline of Coverage |
PPO-STM-3-OLC-2 | 01/2010 |
| SelecTEMP PPO Patient Protection Act Disclosure Statement |
PPO-STM-3-PPA-1 | 01/2010 |
| PPO Select Choice Outline of Coverage (Series IV) |
PPO-SELCHOICE-3-OLC-7 | 09/2011 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-SELCHOICE-3-OLC-6 SP | 10/2010 |
| PPO Select Choice Patient Protection Act Disclosure Statement (Series IV) |
PPO-SELCHOICE-3-PPA-5 | 10/2010 |
| PPO Select Saver Outline of Coverage (Series IV) |
PPO-SELSAVER-3-OLC-6 | 09/2011 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-SELSAVER-3-OLC-5 SP | 10/2010 |
| PPO Select Saver Patient Protection Act Disclosure Statement (Series IV) |
PPO-SELSAVER-3-PPA-4 | 10/2010 |
| Select Blue Advantage Outline of Coverage (Series IV) |
PPO-SELBLU-ADV-3-OLC-6 | 09/2011 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA |
PPO-SELBLU-ADV-3-OLC-5 SP | 10/2010 |
| Select Blue Advantage Patient Protection Act Disclosure Statement (Series IV) |
PPO-SELBLUE-ADV-3-PPA-4 | 10/2010 |
| Blue Pathway Outline of Coverage |
BLUE PATHWAY-OLC-1 | 09/2011 |
| General Miscellaneous Forms | Form # | Revision Date |
| Consumer Markets Producer Agreement Commission Schedule |
N/A | 1/2011 |
| Producer of Record Transfer Form |
N/A | 5/2011 |
| Producer Commission Electronic Funds Transfer Form |
N/A | 5/2011 |
| Automatic Premium Payment Authorization Agreement |
51436.0711 | 07/2011 |
| Acuerdo de autorizacion para el pago de prima automatico |
49218.0409 | 04/2009 |
| BlueEdge Individual HSA Amendment (Effective 1-1-10) |
51849.0110 | 01/2010 |
| Blue Pathway Sales Flier |
53398.0611 | 06/2011 |
| List Bill Agreement |
51178.0109 | 01/2009 |
| Continuation of Coverage Request Form |
47133.0109 | 01/2009 |
| Plan Comparison Chart |
43378.0112 | 01/2012 |
| Multiple Dependent Applications Instructions |
N/A | 05/2008 |
| PrimeMail Mail Order Prescription Form |
40690.1210 | 12/2010 |
| Prescription Reimbursement Claim Form |
40959-704 | 07/2004 |
| Medical Claim Form |
1081.000.901 | 09/2001 |
| Medical Claim Form - Spanish Version |
1081.000.901 | 09/2001 |
| Standard Authorization to Use or Disclose Protected Health Information (PHI) |
N/A | 09/2007 |
| Series IV, HSA, Dental Enrollment Guides |
50400.0112 | 01/2012 |
| SelecTEMP PPO Enrollment Flyer |
46086.0511 | 05/2011 |
| Dental Miscellaneous Forms | Form # | Revision Date |
| Dental Indemnity USA Monthly Premium Rate Guide |
N/A | 04/2004 |
| Dental Indemnity USA Outline of Coverage |
IND-DEN-2 OLC-1 |
09/2008 |
| Dental Scheduled Benefit Plan - Region II |
TXGRGNII | 04/2003 |
| Dental Scheduled Benefit Plan - Region IV |
TXGRGNIV | 04/2003 |
Medicare Products
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