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BlueCross BlueShield of Texas Health Care Costs
 

Group Forms

Photocopy and return these completed forms to your employer's human resource department. Keep a copy for your records.

  • Group Enrollment Application/Change Form - Form No. EE/CHG5 0807
    • Existing Blue Cross and Blue Shield of Texas group members must use this form to submit changes to their coverage or personal information such as: a name or address change, to add or drop dependents, or a change to their PCP election. New group members must use this form when enrolling in a Blue Cross and Blue Shield of Texas group product offered by their employer.
  • Formulario de cambios de información/Solicitud de inscripción grupal - Forma de la Politica EE/CHG5-SP 0807
    • Same instructions as stated above for existing and new group members
  • Student Dependent Certification
    • Any Blue Cross and Blue Shield of Texas member can use this form to certify and report a dependent as a student.
  • Change Life Beneficiary
    • Members who have life coverage through Group Life and Health/Fort Dearborn Life Insurance (FDL) can use this form to change beneficiaries on their life policies.
      Policy form R2 X6053 
  • Dependent Child Statement of Disability
    Policy form Disability02 2487.000-202
  • Dependent State Continuation
    • Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage of their current benefits for up to 36 months if coverage is loss due to divorce, death or retirement of the employee.
      Policy form StateContDep06 43942.1106

Photocopy and return these completed claims forms to Blue Cross and Blue Shield of Texas. Keep a copy for your records.

Medical Claim Form
Blue Cross and Blue Shield of Texas members who have PPO, or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers.
Policy form 1081.000-901

Medical Claim Form - Spanish Version
Forma de la Politica 1081.000-901 SP

HMO Blue® Texas Medical Claim Form
HMO Blue® Texas members can use this form to file claims for reimbursement that are not filed by their providers.
Policy form MBRCLM102 8708.995-102

Dental Claim Form
Members with dental coverage through Blue Cross and Blue Shield of Texas can use this form to file dental claims for reimbursement that are not filed by their providers.

Standard Authorization Form to Use or Disclose Protected Health Information (PHI)
This form should be used only by members who have a group health insurance policy through their employer.  


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a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association.
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