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)  (90 KB) |
IND-APP/MCF-3REV | 01/2011 |
| BlueEdge 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-2 | 05/2011 |
| 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 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. (78 KB) |
IND-MCF-Non-UW-3 | 01/2011 |
| 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 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. (110 KB) |
IND-MCF-UW-3REV | 01/2011 |
| 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. (85 KB) |
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 (97 KB) |
PPO-IND-CCHBP-MCF(B)-4REV | 01/2011 |
| PPO Select Value Care Miscellaneous Change Form (109 KB) |
PPO-IND-VALUE-APP/MCF-3REV | 01/2011 |
| Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series IV) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. (85 KB) |
IND-APP(SO)-2REV | 01/2011 |
| Formulario de cambios varios/de solicitud This is the Spanish version of the Series IV Application/Miscellaneous Change Form. |
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 (126 KB) |
PPO-BLUEEDGE-INDL-HSA-OLC-10 | 09/2011 |
| BlueEdge Individual HSA Patient Protection Act Disclosure Statement (243 KB) |
PPO-BLUEEDGE-INDL-HSA-PPA-8 | 10/2010 |
| SelecTEMP PPO Outline of Coverage (312 KB) |
PPO-STM-3-OLC-2 | 01/2010 |
| SelecTEMP PPO Patient Protection Act Disclosure Statement (131 KB) |
PPO-STM-3-PPA-1 | 01/2010 |
| PPO Select Choice Outline of Coverage (Series IV) (126 KB) |
PPO-SELCHOICE-3-OLC-7 | 09/2011 |
| PPO Select Choice INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Choice Outline of Coverage. (440 KB) |
PPO-SELCHOICE-3-OLC-6 SP | 10/2010 |
| PPO Select Choice Patient Protection Act Disclosure Statement (Series IV) (102 KB) |
PPO-SELCHOICE-3-PPA-5 | 10/2010 |
| PPO Select Saver Outline of Coverage (Series IV) (122 KB) |
PPO-SELSAVER-3-OLC-6 | 09/2011 |
| PPO Select Saver INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the PPO Select Saver Outline of Coverage. (436 KB) |
PPO-SELSAVER-3-OLC-5 SP | 10/2010 |
| PPO Select Saver Patient Protection Act Disclosure Statement (Series IV) (107 KB) |
PPO-SELSAVER-3-PPA-4 | 10/2010 |
| Select Blue Advantage Outline of Coverage (Series IV) (133 KB) |
PPO-SELBLU-ADV-3-OLC-6 | 09/2011 |
| Select Blue Advantage INFORMACION GENERAL DE LA COBERTURA REQUERIDA This is the Spanish version of the Select Blue Advantage Outline of Coverage. (443 KB) |
PPO-SELBLU-ADV-3-OLC-5 SP | 10/2010 |
| Select Blue Advantage Patient Protection Act Disclosure Statement (Series IV) (109 KB) |
PPO-SELBLUE-ADV-3-PPA-4 | 10/2010 |
| Blue Pathway Outline of Coverage (104 KB) |
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 Effective May 1, 2011, this form should be completed when a BCBSTX policyholder wants to give their Producer access to specified sections of their PHI. |
N/A | 5/2011 |
Producer Commission Electronic Funds Transfer Form  Use this form to set up a new electronic funds transfer (EFT) payment program or to change your existing EFT payment program. The form can be mailed or faxed to the Broker Administration Department at Blue Cross and Blue Shield of Texas. Address and fax number are included in the form. (52 KB) |
N/A | 5/2011 |
| Automatic Premium Payment Authorization Agreement Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. (95 KB) |
51436.0711 | 07/2011 |
| 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) |
49218.0409 | 04/2009 |
| BlueEdge Individual HSA Amendment (Effective 1-1-10) (899 KB) |
51849.0110 | 01/2010 |
| Blue Pathway Sales Flier (275 KB) |
53398.0611 | 06/2011 |
| 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 | 01/2009 |
| 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 | 01/2009 |
| Plan Comparison Chart (348 KB) |
43378.0112 | 01/2012 |
| Multiple Dependent Applications Instructions (128 KB) |
N/A | 05/2008 |
| PrimeMail Mail Order Prescription Form (137 KB) |
40690.1210 | 12/2010 |
| Prescription Reimbursement Claim Form (146 KB) |
40959-704 | 07/2004 |
| Medical Claim Form (18 KB) |
1081.000.901 | 09/2001 |
| Medical Claim Form - Spanish Version (72 KB) |
1081.000.901 | 09/2001 |
| 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 | 09/2007 |
| Series IV, HSA, Dental Enrollment Guides (2,661 KB) |
50400.0112 | 01/2012 |
| SelecTEMP PPO Enrollment Flyer This form should be used only by members who have an Individual health insurance policy. |
46086.0511 | 05/2011 |
| Dental Miscellaneous Forms | Form # | Revision Date |
| Dental Indemnity USA Monthly Premium Rate Guide (19 kb) |
N/A | 04/2004 |
| Dental Indemnity USA Outline of Coverage (495 kb) |
IND-DEN-2 OLC-1 |
09/2008 |
| Dental Scheduled Benefit Plan - Region II (25 kb) |
TXGRGNII | 04/2003 |
| Dental Scheduled Benefit Plan - Region IV (22 kb) |
TXGRGNIV | 04/2003 |
Medicare Products
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