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

Here are some commonly used forms and documents producers need for conducting business with Blue Cross and Blue Shield of Texas. To access more downloadable forms, please log in your Blue Access for ProducersSM account.

Using PDFs
Most of 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®. Other Adobe accessibility tools and information can be downloaded at access.adobe.com.

“Sign Now” Documents
Some documents have a “sign now” option. To review and sign a document now electronically, select the sign now version. If you need to sign a document later, select the download version. Most versions are in PDF format, and some may also be available in Microsoft Word format.

Download forms from the listing below or via our FormFinder tool.

 

Enrollment Forms and Change Forms

Form Name Digital Form Download

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

N/A download form

Group Enrollment Application/Change Form – Spanish

N/A download form

2024 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/24 and after

sign now N/A

2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/24 and after

sign now download form
download form Word Document

2023–2024 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

N/A download notice

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

sign now N/A

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

sign now download form
download form Word Document

Benefit Program Application (BPA) for HCA Insured Group Plans

N/A download form
download form Word Document

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

sign now download form

Affidavit of Domestic Partnership

sign now download form

Affidavit of Domestic Partnership – Spanish

N/A download form

Away From Home Care Guest Membership Application – for HMO members

N/A download form

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

N/A download form

COBRA Continuation of Coverage Application & Social Security Disability Form

N/A download form

COBRA Initial Notice Requirements

N/A download notice

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 HealthEquity or HSA Bank.

N/A download form

Dependent Addition and Change Form for Court-Mandated Health Coverage

N/A download form

Dependent State Continuation of Coverage Form

sign now download form

Dependent Student Medical Leave Certification Form

N/A download form

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 download form

Group Proxy Letter/Form – included in BPA

N/A download form

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

N/A download form

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.

N/A download form

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.

N/A download form

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.

N/A download form
Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. sign now download form
Average Employee Count (AEC) Form sign now download form

Mid-Market Request for Proposal Form

N/A download form

Mid-Market Quote Request Checklist

N/A download form

RCI Utilizers Request Form

N/A download form
download form Word Document

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

N/A N/A

Student Certification Form

N/A download form

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

sign now download form

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

sign now download form

 

Claim Forms and Order Forms

Form Name Digital Form Download

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

N/A download form
Dental Claim Form – Spanish N/A download form

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 download form

Medical Claim Form (Domestic) – Spanish

N/A download form

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 download form

Medical Claim Form (International) – Spanish

N/A download form

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 download form

Prescription Drug Claim Form (Prime Therapeutics) – Spanish

N/A download form

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 download form

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

N/A download form

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download

Annual MSP Employer Acknowledgement Form (EAF) with Instructions

sign now download form

Information Regarding MSP Statute

N/A download flyer

MSP Fact Sheet

N/A download fact sheet

 

Miscellaneous Forms

Form Name Digital Form Download

Dental Provider Nomination Form

N/A download form

Group Profile Update Form

N/A download form

Producer of Record Transfer Form

N/A download form

Producer Commission Electronic Funds Transfer Form

N/A download form

 

Legal / HIPAA Forms

Form Name Digital Form Download

Standard Authorization Form and other HIPAA Privacy Forms

N/A

access forms

 

Last Updated: Feb. 26, 2024