Downloadable Forms for Mid-Market Group Products (Groups of 51-150)

Enrollment Forms and Change Forms

Form Name Digital Form Download

2021/2022 Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSTX policy

N/A download form

2021/2022 Group Enrollment Application/Change Form – Spanish

N/A download form

Affidavit of Domestic Partnership

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Affidavit of Domestic Partnership – Spanish

N/A download form

COBRA Continuation of Coverage Application & Social Security Disability Form

N/A download form

COBRA Initial Notice Requirements

N/A download form

Dependent Addition and Change Form for Court-Mandated Health Coverage

N/A download form

Dependent State Continuation of Coverage Form

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Dependent Student Medical Leave Form

N/A download form

Dependent Student Medical Leave Form – Spanish

N/A download form

Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSTX (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).

N/A download form

Student Certification Form

N/A download form

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

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

N/A download form

 

Claim Forms and Order Forms

Form Name Digital Form Download

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

N/A download form

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 download form

Medical Claim Form (Domestic) – Spanish

N/A download form

Medical Claim Form (International) – Members should use this 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 download form

Medical Claim Form (International) – Spanish

N/A download form

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

N/A download form

Prescription Drug Claim Form (Prime Therapeutics) – Spanish

N/A download form

Prescription Drug Mail-Order Form (Express Scripts) – Members with prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. They need to mail the completed form to the address provided on the form, and include the original prescription signed by their doctor.

N/A download form

Prescription Drug Mail-Order Form (Express Scripts) – Spanish

N/A download form

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download

Annual MSP Employer Acknowledgement Form (EAF) with Instructions

N/A download form

Information Regarding MSP Statute

N/A download form

MSP Fact Sheet

N/A download form

 

Legal / HIPAA Forms

Form Name Digital Form Download

Standard Authorization Form and other HIPAA Privacy Forms

N/A

N/A