Blue Access for Employers

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 #

45331.1017

Affidavit of Domestic Partnership 

N/A

732948.1017

Affidavit of Domestic Partnership – Spanish 

N/A

TXBPASG-OFF-EX 06.18

2019 Benefit Program Application BPA) for New Small Groups 2-50  – for new accounts effective on or after 1/1/2019

N/A

TXBPASG-OFF-EX-AMD 06.18

2019 Benefit Program Application (BPA) Amendment for Small Groups 2-50  – for renewing accounts with anniversary dates on or after 1/1/2019; use this form to amend the original BPA

N/A

TXBPASG-OFF-EX 01.18

2018 Benefit Program Application BPA) for New Small Groups 2-50  – for new accounts effective on or after 1/1/2018

N/A

TXBPASG-OFF-EX-AMD 01.18

2018 Benefit Program Application (BPA) Amendment for Small Groups 2-50  – for renewing accounts with anniversary dates on or after 1/1/2018; 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

730197.0817

2018 Group Enrollment Application/Change Form 

NA

726435.0817

2018 Group Enrollment Application/Change Form – Spanish 

NA

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

2487.000.0317

Dependent Child's Statement of Disability Form 

N/A

732947.1017

Dependent Child's Statement of Disability Form – Spanish 

N/A

TX SG EGI

Employer Group Information (EGI) Form  – this form must be submitted with the BPA

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 

N/A

 

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