Downloadable Forms for Mid-Market 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® .
MID-MARKET GROUP FORMS (Groups of 51-150) | ||
---|---|---|
Stock # / Date | Enrollment Forms and Change Forms | Texas Form # |
45331.1017 |
N/A |
|
732948.1017 |
N/A |
|
730197.0120 |
2020 Group Enrollment Application/Change Form |
NA |
726435.0120 |
NA |
|
730197.0817 |
NA |
|
726435.0817 |
NA |
|
05253.1106 |
COBRA Continuation of Coverage Application & Social Security Disability Form |
N/A |
0009.443-0804 |
N/A |
|
745103.0317 |
Dependent Addition and Change Form for Court-Mandated Health Coverage |
GDA-CMHC-02 |
745104.0317 |
N/A |
|
53947.0317 |
N/A |
|
732949.0717 |
N/A |
|
2487.000.0317 |
N/A |
|
732947.1017 |
N/A |
|
745108.0317 |
N/A |
|
53594.0916 |
Texas Nine (9) Month State Continuation of Insurance Application Form |
TX.9month.Cont.11 |
53780.0916 |
Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA) |
6month.PostCOBRA. Cont.11 |
Stock # / Date | Claim Forms and Order Forms | Texas Form # |
J30D |
Dental Claim Form |
N/A |
735026.0915 |
Medical Claim Form (Domestic) |
N/A |
731140.0116 |
Medical Claim Form (Domestic) – Spanish |
N/A |
16-581-N35 |
Medical Claim Form (International) |
N/A |
3272 TX |
Prescription Drug Claim Form |
N/A |
WI0361-0817 |
PrimeMail Order Form |
N/A |
Stock # / Date | Medicare Secondary Payer (MSP) Form and Information | Texas Form # |
21125.0913 |
N/A |
|
21092.0609 |
N/A |
|
56084.0612 |
N/A |
|
Stock # / Date | Legal / HIPAA Forms | Texas Form # |
04.01.18 |
N/A |
|
53715.0415 |
N/A |