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Downloadable Forms for Small Group Products (2-50)


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.

To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.


Enrollment Forms and Change Forms


Form Name Digital Form Download

2017 Enrollment Package – Includes 2017 Benefit Program Application (BPA) for New Small Groups 2-50, Employer Group Information (EGI) Form, and Artifacts Documentation

sign now External Link N/A

2016 Enrollment Package – Includes 2016 Benefit Program Application (BPA) for New Small Groups 2-50, Employer Group Information (EGI) Form, and Artifacts Documentation

sign now External Link N/A

2017 Benefit Program Application (BPA) for New Small Groups 2-50 – for accounts effective 1/1/17 and after

sign now External Link download form Word Document

2016 Benefit Program Application (BPA) for Small Groups 2-50 – for accounts effective on or after 1/1/2016

sign now External Link download form Word Document

2017 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2017; use this form to amend the original BPA

N/A download form Word Document

2016 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA

N/A download form Word Document

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

sign now External Link download form Acrobat PDF

Texas Universal Application

sign now External Link N/A

Affidavit of Domestic Partnership

sign now External Link download form Acrobat PDF

Away From Home Care Guest Membership Application – for HMO members

N/A download form Acrobat PDF

2016 Group Enrollment Application/Change Form

sign now External Link download form Acrobat PDF

COBRA Continuation of Coverage Application & Social Security Disability Form

N/A download form Acrobat PDF

COBRA Initial Notice Requirements

N/A download form Acrobat PDF

Composite Rate Billing Method Declaration Form (2016) – for new and existing fully insured accounts (up to 50 employees). Includes Reference Guide to Composite Rating for 2016 Accounts.

sign now External Link download form Acrobat PDF

Composite Rate Billing Frequently Asked Questions – FAQs about composite billing available for new and existing fully insured accounts (up to 50 employees), effective January 2016.

N/A download form Acrobat PDF

Dependent Addition and Change Form for Court-Mandated Health Coverage

N/A download form Acrobat PDF

Dependent State Continuation of Coverage Form

sign now External Link download form Acrobat PDF

Dependent Student Medical Leave Form

N/A download form Acrobat PDF

Disabled Dependent Certification Form

sign now External Link download form Acrobat PDF

Group Proxy Letter/Form – included in BPA

N/A download form Acrobat PDF

Request for Proposal/Census for Regulated Small Groups 2-50

N/A download form Acrobat PDF

Student Certification Form

N/A download form Acrobat PDF

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

sign now External Link download form Acrobat PDF

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

N/A download form Acrobat PDF

Texas Supplemental Employment Verification Form

sign now External Link download form Acrobat PDF

 

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 Acrobat PDF

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 Acrobat PDF

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 download form Acrobat PDF

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 download form Acrobat PDF

Prescription Drug Claim Form &ndsh; 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 download form Acrobat PDF

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 download form Acrobat PDF

 

Miscellaneous Forms


Form Name Digital Form Download

Dental Provider Nomination Form

N/A download form Acrobat PDF

Group Profile Update Form

N/A download form Acrobat PDF

Producer Commission Electronic Funds Transfer Form

N/A download form Acrobat PDF

Small Group Employee Contribution Level Calculator

N/A download form Acrobat PDF

 

Medicare Secondary Payer (MSP) Form and Information


Form Name Digital Form Download

Annual MSP Employer Acknowledgement Form with Instructions

N/A download form Acrobat PDF

Information Regarding MSP Statute

N/A download form Acrobat PDF

MSP Fact Sheet

N/A download form Acrobat PDF

 

Legal / HIPAA Forms


Form Name Digital Form Download

Standard Authorization Form and other HIPAA Privacy Forms

N/A

N/A

 

Tip Sheets and Brochures


Form Name Digital Form Download

Quote Requests Checklist for Small Groups (2-50) – for off-exchange plans effective January 1, 2014

N/A download form Acrobat PDF

Small Group Important Timelines (2014)

N/A download form Acrobat PDF

Small Group Submission Checklist (2016)

N/A download form Acrobat PDF