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 |
2023 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after | sign now | N/A |
2023 Benefit Program Application (BPA) – for accounts effective 1/1/23 and after |
N/A | download form ![]() download form |
2023 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA |
sign now | download form ![]() download form |
Employer Group Information (EGI) Form – this form must be submitted with the BPA |
N/A |
download form |
2022 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after |
sign now | N/A |
2022 Benefit Program Application (BPA) – for accounts effective 1/1/22 and after |
sign now | download form ![]() download form |
2022 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2022; use this form to amend the original BPA |
sign now | download form ![]() download form |
Affidavit of Domestic Partnership |
sign now | download form |
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 notice |
Dependent Addition and Change Form for Court-Mandated Health Coverage |
N/A | download form |
Dependent State Continuation of Coverage Form |
sign now | download form |
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 |
HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity. |
N/A | download form |
HSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form if you wish to open accounts for your employees at HSA Bank. |
N/A | download form |
HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form if you wish to open accounts for your employees at Benefit Wallet. |
N/A | download form |
Student Certification Form |
N/A | download form |
Texas Nine (9) Month State Continuation of Insurance Application Form |
sign now | download form |
Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA) |
sign now | download form |
Form Name | Digital Form | Download |
---|---|---|
2023 Important Benefit Changes for Texas Small Group Plans – identifies some of the most important benefit plan changes for the upcoming 2023 coverage year |
N/A | download letter |
2023 Important Benefit Changes for all Texas Group Plans – identifies some of the most important benefits for plans effective 1/1/2023 | N/A | download letter |
2023 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA |
N/A | download form ![]() download form |
2022 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2022; use this form to amend the original BPA |
sign now | download form ![]() download form |
HMO Disclosure Notice Form – use this form when making any changes to HMO small group plans offered for next year; the form is also included within the 2022 BPA Amendment. This is a Texas Department of Insurance required Disclosure Notice for all small group HMO Consumer Choice benefit plans issued in Texas. |
N/A | download form |
2022 Important Benefit Changes/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2022 coverage year |
N/A | download letter |
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 |
Dental Claim Form – Spanish | 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 purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. For prescription drugs, you must submit the original pharmacy receipt with the completed form. For COVID-19 home test kits, you must submit the original cash register or online 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 |
Form Name | Digital Form | Download |
---|---|---|
Producer of Record Transfer Form and Instructions | N/A | download form |
Form Name | Digital Form | Download |
---|---|---|
Annual MSP Employer Acknowledgement Form (EAF) with Instructions |
N/A | download form |
Information Regarding MSP Statute |
N/A | download flier |
MSP Fact Sheet |
N/A | download fact sheet |
Form Name | Digital Form | Download |
---|---|---|
N/A |
N/A |