Blue Access for Producers

Downloadable Forms for Small Group Products


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX). To access more downloadable forms, please log in to Blue Access for Producers. The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® .

 

 
SMALL GROUP FORMS (Groups of 2-50) 
Stock # / Date Enrollment Forms and Change Forms Texas Form #

11/2012

Affidavit of Domestic Partnership 

N/A

N/A

Away From Home Care Guest Membership Application  – for HMO members

N/A

TXBPASG-OFF-EX 01.16 2016 Benefit Program Application (BPA) for New Small Groups 2-50  – for new accounts effective on or after 1/1/2016 N/A
TXBPASG-OFF-EX-AMD 01.16 2016 Benefit Program Application (BPA) Amendment for Small Groups 2-50  – for renewing accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA N/A
TXBPASG-OFF-EX 11.14 2015 Benefit Program Application (BPA) for New Small Groups 2-50  – for new or existing accounts effective on or after 1/1/2015 N/A
TXBPASG-OFF-EX-AMD 11.14 2015 Benefit Program Application (BPA) Amendment for Existing Small Groups 2-50  – for existing accounts enrolled on or after 1/1/2015; use this form to amend the original BPA N/A
TX HCA for Insured No Fee Rev. 3.13 Benefit Program Application (BPA) for HCA Insured Group Plans  – for accounts effective on or after 1/1/2015 N/A

730197.0216

2016 Group Enrollment Application/Change Form 

NA

05253.1106

COBRA Continuation of Coverage Application & Social Security Disability Form 

N/A

0009.443-0804

COBRA Initial Notice Requirements 

N/A

10/2015

Composite Rate Billing Method Declaration Form (2016)  - for new and existing fully insured accounts (up to 50 employees). Includes Reference Guide to Composite Rating for 2016 Accounts.

N/A

10/2015

Composite Rate Billing Frequently Asked Questions  - FAQs about composite billing available for new and existing fully insured accounts (up to 50 employees), effective January 2016.

N/A

2849.276-502

Dependent Addition and Change Form for Court-Mandated Health Coverage 

GDA-CMHC-02

43942.1106

Dependent State Continuation of Coverage Form 

N/A

53947.0111

Dependent Student Medical Leave Form 

N/A

2487.000-202

Disabled Dependent Certification Form 

N/A

TX SG EGI

Employer Group Information (EGI) Form  – this form must be submitted with the BPA

N/A

FC849 7/83

Group Proxy Letter/Form  – included in BPA

NA

728117.0814

Request for Proposal/Census for Regulated Small Groups 2-50 

NA

54545.0611

Student Certification Form 

N/A

53594.1011

Texas Nine (9) Month State Continuation of Insurance Application Form 

TX.9month.Cont.11

53780.1011

Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA)  

6month.PostCOBRA. Cont.11

09/2009

Texas Supplemental Employment Verification Form 

N/AB

Stock # / Date Claim Forms and Order Forms Texas Form #

55352.0413

Dental Claim Form  – Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.

N/A

735026.0915

Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.

N/A

731140.0116

Medical Claim Form (Domestic) – Spanish – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.

N/A

N-12-420

Medical Claim Form (International) – Members should use this BlueCard Worldwide claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.

N/A

3272 TX
01/16

Prescription Drug Claim Form – Members with pharmacy benefits through BCBSTX can use this form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSTX pharmacy benefits manager.

N/A

3208 TX
04/16

PrimeMail Order Form  – Members with prescription drug coverage can use this form to mail order new or refill prescription maintenance medication. Mail the completed form to PrimeMail and include the original prescription signed by the prescribing doctor.

N/A

Stock # / Date Miscellaneous Forms Texas Form #

TX_012014

Dental Provider Nomination Form 

N/A

N/A

Group Profile Update Form 

N/A

10-16-26

Producer Commission Electronic Funds Transfer Form 

N/A

03.31.2011

Small Group Employee Contribution Level Calculator 

N/A

Stock # / Date Medicare Secondary Payer (MSP) Form and Information Texas Form #

21125.0913

Annual MSP Employer Acknowledgement Form with Instructions 

N/A

21092.0609

Information Regarding MSP Statute 

N/A

56084.0612

MSP Fact Sheet 

N/A

Stock # / Date Legal / HIPAA Forms Texas Form #

08.01.15

Standard Authorization Form and other HIPAA Privacy Forms

N/A

Stock # / Date Tip Sheets and Brochures Texas Form #

726016.1013

Quote Requests Checklist for Small Groups (2-50 – for off-exchange plans effective January 1, 2014

N/A

725874.0913

Small Group Important Timelines (2014) 

N/A

730767.1015

Small Group Submission Checklist (2016) 

N/A

 

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