Downloadable Forms for Mid-Market Group Products (Groups of 51-150)

Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSTX policy

Group Enrollment Application/Change Form – Spanish

2023 Important Benefit Change/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2023 coverage year

2023 Mid-Market/Large Group Important Benefit Change/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2023-2024 coverage year

2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/23 and after

2023 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after

2022 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after

2022 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/22 and after

Benefit Program Application (BPA) for HCA Insured Group Plans

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

Affidavit of Domestic Partnership

Affidavit of Domestic Partnership – Spanish

Away From Home Care Guest Membership Application – for HMO members

Away From Home Care Guest Membership Application – Spanish – for HMO members

Benefit Wallet^® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with BenefitWallet.

COBRA Continuation of Coverage Application & Social Security Disability Form

COBRA Initial Notice Requirements

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSTX to BenefitWallet, HealthEquity or HSA Bank.

Dependent Addition and Change Form for Court-Mandated Health Coverage

Dependent State Continuation of Coverage Form

Dependent Student Medical Leave Form

Dependent Student Medical Leave Form – Spanish

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).

Group Proxy Letter/Form – included in BPA

HSA Employer Setup Form – Benefit Wallet^® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet.

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

HSA/FSA Employer Setup Form – HealthEquity^® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

HSA/FSA Employer Setup Form – HSA Bank^® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.

Mid-Market Request for Proposal Form

Mid-Market Quote Request Checklist

RCI Utilizers Request Form

Smart Census Import Tool
(To obtain the latest version of the tool, please log into Blue Access for Producers.)

Student Certification Form

Texas Nine (9) Month State Continuation of Insurance Application Form

Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA) 

Dental Claim Form – Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.

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.

Medical Claim Form (Domestic) – Spanish

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.

Medical Claim Form (International) – Spanish

Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSTX can use this claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. They must submit the pharmacy counter receipt with the completed form. Cash register receipts for OTC COVID-19 test kits may not be accepted. Not all plans cover OTC COVID-19 home test kits. If the member's plan does not cover, they will not be reimbursed.

Prescription Drug Claim Form (Prime Therapeutics) – Spanish

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.

Prescription Drug Mail-Order Form (Express Scripts) – Spanish

Annual MSP Employer Acknowledgement Form (EAF) with Instructions

Information Regarding MSP Statute

MSP Fact Sheet

Dental Provider Nomination Form

Group Profile Update Form

Producer of Record Transfer Form

Producer Commission Electronic Funds Transfer Form

Standard Authorization Form and other HIPAA Privacy Forms

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