Downloadable Forms for Mid-Market Group Products

45331.1017

Affidavit of Domestic Partnership  

N/A

732948.1017

Affidavit of Domestic Partnership – Spanish  

N/A

730197.0120

2020 Group Enrollment Application/Change Form  – Use this form to apply for group coverage effective 1/1/2020, or to make changes to an existing BCBSTX policy

NA

726435.0120

2020 Group Enrollment Application/Change Form – Spanish  

NA

730197.0817

2018 Group Enrollment Application/Change Form  

NA

726435.0817

2018 Group Enrollment Application/Change Form – Spanish  

NA

05253.1106

COBRA Continuation of Coverage Application & Social Security Disability Form  

N/A

0009.443-0804

COBRA Initial Notice Requirements  

N/A

745103.0317

Dependent Addition and Change Form for Court-Mandated Health Coverage 

GDA-CMHC-02

745104.0317

Dependent State Continuation of Coverage Form 

N/A

53947.0317

Dependent Student Medical Leave Form  

N/A

732949.0717

Dependent Student Medical Leave Form – Spanish  

N/A

751236.0819

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

745108.0317

Student Certification Form  

N/A

53594.0916

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

TX.9month.Cont.11

53780.0916

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

6month.PostCOBRA. Cont.11

J30D

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

N/A

735026.0915

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

731140.0116

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

16-581-N35

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

3272 TX
01/16

Prescription Drug Claim Form   – 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

WI0361-0817

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

21125.0913

Annual MSP Employer Acknowledgement Form with Instructions 

N/A

21092.0609

Information Regarding MSP Statute 

N/A

56084.0612

MSP Fact Sheet 

N/A

04.01.18

Standard Authorization Form and other HIPAA Privacy Forms

N/A

53715.0415

Important Notices

Important Notices

N/A