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 7.14 Benefit Program Application (BPA) for New Small Groups 2-50  – for new or existing accounts effective on or after 1/1/2015 8.2014
TXBPASG-OFF-EX-AMD 7.14 Benefit Program Application (BPA) Amendment for Existing Groups 2-50  – for existing accounts enrolled on or after 1/1/2015 – use this form to amend the original BPA 8.2014
TXBPASG-OFF-EX 8.13
10.2013
Benefit Program Application (BPA) for New Small Groups 2-50  – for new accounts effective on or after 1/1/2014 N/A
TXBPASG-OFF-EX-AMD 8.13
10.2013
Benefit Program Application (BPA) Amendment for Existing Groups 2-50  – for existing accounts enrolled on or after 1/1/2014 – use this form to amend the original BPA N/A
TXPBASG1A9.12
10.2012
Benefit Program Application (BPA) Amendment for Existing Groups 2-50  – for existing accounts enrolled before 1/1/2014 – 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

R2/07 x6053

Change Life Beneficiary 

N/A

05253.1106

COBRA Continuation of Coverage Application & Social Security Disability Form 

N/A

0009.443-0804

COBRA Initial Notice Requirements 

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

728117.0814

Group Enrollment Application/Change Form (2015) 

NA

726435.0115

Group Enrollment Application/Change Form (2015) – Spanish 

NA

FC849 7/83

Group Proxy Letter/Form  – included in BPA

NA

728363.0914

Pediatric Dental – Small Group Attestation Form - Employer 

NA

726024.1114

Pediatric Dental – Small Group Attestation Form - Member 

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 #

53791.1110

BlueEdge HCA Non-PPO Eligible Expenses Claim Form 

N/A

55352.0413

Dental Claim Form 

N/A

1081.000-901

Medical Claim Form 

N/A

1081.000-901 SP

Medical Claim Form – Spanish 

N/A

8708.995-102

Medical Claim Form – HMO 

N/A

40959.0112

Prescription Drug Claim Form  – for Group Plan members

N/A

3208-TX NEW

PrimeMail New Prescription Order Form 

N/A

3208-TX REFILL

PrimeMail Refill Prescription Order Form 

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 #

09.01.13

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

727377.0514

Small Group Submission Timelines (2014) 

N/A

50203.0614

Tips for Submitting New Small Groups (2014) 

N/A

 

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