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	Affidavit of Domestic Partnership	N/A
732948.1017	Affidavit of Domestic Partnership – Spanish	N/A
730197.0120	2020 Group Enrollment Application/Change Form – Use this form to apply for group coverage effective 1/1/2020, or to make changes to an existing BCBSTX policy	NA
726435.0120	2020 Group Enrollment Application/Change Form – Spanish	NA
730197.0817	2018 Group Enrollment Application/Change Form	NA
726435.0817	2018 Group Enrollment Application/Change Form – Spanish	NA
05253.1106	COBRA Continuation of Coverage Application & Social Security Disability Form	N/A
0009.443-0804	COBRA Initial Notice Requirements	N/A
745103.0317	Dependent Addition and Change Form for Court-Mandated Health Coverage	GDA-CMHC-02
745104.0317	Dependent State Continuation of Coverage Form	N/A
53947.0317	Dependent Student Medical Leave Form	N/A
732949.0717	Dependent Student Medical Leave Form – Spanish	N/A
751236.0819	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
745108.0317	Student Certification Form	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 – 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
16-581-N35	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
WI0361-0817	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	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 #
04.01.18	Standard Authorization Form and other HIPAA Privacy Forms	N/A
53715.0415	Important Notices Important Notices	N/A

Downloadable Forms for Mid-Market Group Products

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