Downloadable Forms for Individual & Family Markets

Here are some commonly used forms and documents for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX). 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®.

Note: Please provide the Texas Department of Insurance Notice to your clients seeking a PPO plan at the same time as you provide the Outline of Coverage.

PLEASE READ: Texas Department of Insurance required Disclosure Notice (EnglishSpanish) for all individual HMO Consumer Choice benefit plans issued in Texas.

 

Current Forms and Documents

 
Stock # / Date Enrollment Forms and Change Forms Texas Form #
745718.1023 2024 Individual Paper Application Checklist N/A
746129.1123 2024 Individual Paper Application Checklist (Spanish Version) N/A
57330.0124 2024 Health Application/Change in Coverage 
Use this health application for 2024 plans effective January 1, 2024.
UN65-APP-Off-EX-2024
725600.0124 2024 Health Application/Change in Coverage (Spanish Version) UN65-APP-Off-EX-2024SP
57784.0124 2024 Dental Application/Change in Coverage 
Use this dental application for 2024 plans effective January 1, 2024.
APP-DENT-IND-2024
725603.0124 2024 Dental Application/Change in Coverage (Spanish Version) APP-DENT-IND-2024SP
727791.1023 2024 Individual Paper Application Overflow Page
If you run out of room on the primary application for health plan coverage, use this form to add more dependents to your policy. Use this dental application for 2024 plans effective January 1, 2024.
UN65-APP-Off-EX-2024-O
727808.1123 2024 Individual Paper Application Overflow Page (Spanish Version) UN65-APP-Off-EX-2024SP-O
745718.1022 2023 Individual Paper Application Checklist N/A
746129.1122 2023 Individual Paper Application Checklist (Spanish Version) N/A
57330.1022 2023 Health Application/Change in Coverage 
Use this health application for 2023 plans effective January 1, 2023.
UN65-APP-Off-EX-2023
725600.1122 2023 Health Application/Change in Coverage (Spanish Version) UN65-APP-Off-EX-2023SP
57784.1022 2023 Dental Application/Change in Coverage 
Use this dental application for 2023 plans effective January 1, 2023.
APP-DENT-IND-2023
725603.1122 2023 Dental Application/Change in Coverage (Spanish Version) APP-DENT-IND-2023SP
727791.1022 2023 Individual Paper Application Overflow Page UN65-APP-Off-EX-2023-O
727808.1122 2023 Individual Paper Application Overflow Page (Spanish Version) UN65-APP-Off-EX-2023SP-O
     
Stock # / Date Benefit Highlights Forms Texas Form #
2023
N/A Blue Advantage Gold HMO 206 TBA
N/A Blue Advantage Bronze HMO 301 TBA
N/A Blue Advantage Bronze HMO 302 TBA
N/A Blue Advantage Bronze HMO 702 TBA
N/A Blue Advantage Bronze HMO 704 TBA
N/A Blue Advantage Bronze HMO 707 TBA
N/A Blue Advantage Gold HMO 206 TBA
N/A Blue Advantage Gold HMO 207 TBA
N/A Blue Advantage Gold HMO 603 TBA
N/A Blue Advantage Gold HMO 706 TBA
N/A Blue Advantage Plus Bronze 201 TBA
N/A Blue Advantage Plus Bronze 303 TBA
N/A Blue Advantage Plus Bronze 305 TBA
N/A Blue Advantage Plus Bronze 501 TBA
N/A Blue Advantage Plus Bronze 704 TBA
N/A Blue Advantage Plus Bronze 707 TBA
N/A Blue Advantage Plus Gold 203 TBA
N/A Blue Advantage Plus Gold 706 TBA
N/A Blue Advantage Plus Silver 202 TBA
N/A Blue Advantage Plus Silver 306 TBA
N/A Blue Advantage Plus Silver 605 TBA
N/A Blue Advantage Plus Silver 705 TBA
N/A Blue Advantage Security HMO 200 TBA
N/A Blue Advantage Silver HMO 205 TBA
N/A Blue Advantage Silver HMO 306 TBA
N/A Blue Advantage Silver HMO 601 TBA
N/A Blue Advantage Silver HMO 705 TBA
N/A MyBlue Health Bronze 402 TBA
N/A MyBlue Health Gold 403 TBA
N/A MyBlue Health Silver 405 TBA    
 
Stock # / Date Miscellaneous Forms Texas Form #
51436.0222 Auto Bill Pay - Automatic Premium Payment Authorization Agreement 
Reduce the chance of your policy being cancelled for non-payment. Members can use this form to set up electronic payments for their plan. This will allow BCBSTX to deduct the monthly premium from their checking or savings account.
N/A
726665.0322 Auto Bill Pay - Automatic Premium Payment Authorization Agreement (Spanish) N/A
N/A Custodial Parent Affidavit N/A
761433.0623 Disabled Dependent Authorization Form (for Individual Plans)
Members with an Individual 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).
N/A
747142.1018 Responsible Party Form TX-RPF-2018
Stock # / Date Other Benefit/Plan Information Texas Form #
729761.0922 2023 Sales Brochure N/A
725872.0922 2023 Sales Brochure (Spanish) N/A    
Stock # / Date Dental Plan/Benefit Information Texas Form #
TBA 2023 Dental Brochure N/A
TBA 2023 Dental Brochure (Spanish) N/A
TBA BlueCare Dental 4 Kids 1A N/A
TBA BlueCare Dental 4 Kids 1B N/A
TBA BlueCare Dental 1A N/A
TBA BlueCare Dental 1B N/A
TBA BlueCare Dental 1C N/A
TBA BlueCare Dental 2A N/A    
Stock # / Date Claim Forms and Order Forms Texas Form #
758995.0522 Dental Claim Form
Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.
N/A
55353.0413 Dental Claim Form – Spanish N/A
730526.1123 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
731140.1123 Medical Claim Form (Domestic) – Spanish N/A
16-581-N35 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.
N/A
16-581-N35 Medical Claim Form (International) – Spanish N/A
3272 TX
05/23
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. On page 3 of the form, members can get more info on how they may get in-network credit for a cash payment made to an out-of-network pharmacy. 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.
N/A
3272 TX SP
05/23
Prescription Drug Claim Form (Prime Therapeutics) – Spanish N/A
EME47693 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.
N/A
EME47693 Prescription Drug Mail-Order Form (Express Scripts) – Spanish N/A

 

Pre-ACA Individual Forms and Documents

Stock # / Date Enrollment Forms and Change Forms Texas Form #
41745.0517 Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver) IND-APP/MCF-4REV
41745.0111 Series V Application/Miscellaneous Change Form (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) - Spanish Version IND-APP/MCF-3REV SP
42352.0111 Series V Special Offer Application (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) 
This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application
IND-APP(SO)-2REV
733084.0117 Application for Transfer of Coverage
N/A
51164.0217 BlueEdge Individual HSA Application/Miscellaneous Change Form
BLUE EDGE-IND-HSA-APP/MCF-6REV
42320.0111 Foundation Hospital Care Miscellaneous Change Form PPO-INHOSPITAL-APP/MCF-2REV
42684.0111 PPO Select Value Care Miscellaneous Change Form PPO-IND-VALUE-APP/MCF-3REV
41694.0111 PPO Select Basic Miscellaneous Change Form
PPO-IND-CCHBP-MCF(B)-4REV
Stock # / Date Miscellaneous Forms Texas Form #
752154.1119 Auto Bill Pay - Automatic Premium Payment Authorization Agreement Form (for under 65 coverage)
This form is to be used for pre-ACA plans only.  Applies to Individual policies with an effective date prior to 2020.
N/A
07.01.22 Standard Authorization Form and other HIPAA Privacy Forms N/A
Stock # / Date Dental Plan Information Texas Form #
40110.404 Dental Indemnity USA Monthly Premium Rate Guide N/A
0009.374-0908 Dental Indemnity USA Outline of Coverage IND-DEN-2-OLC-1
N/A Dental Scheduled Benefit Plan - Region IV TXGRGNIV

 

Miscellaneous Producer Forms

Form Name Digital Form Download
Producer of Record Transfer Form and Instructions N/A download form

 

Last Updated: Feb. 09, 2024