Group Forms
For your convenience, we've put together the following downloadable forms. Acrobat Reader software will enable you to download these PDF files. If you currently don't have the software, you can get a free copy from the Adobe Systems Incorporated website 
. You can also visit our section on how to download a PDF file for additional information.
Be sure to keep a copy for your records.
Group Products |
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| Form Name | Form # | Revision Date |
Spreadsheet Enrollment Template  Utilize this form when enrolling 51-150 employees and submit with paperwork.(38KB, Excel) |
N/A | 09/2010 |
Change Life Beneficiary  Members who have life coverage through Group Life and Health/Dearborn National can use this form to change beneficiaries on their life policies.(30KB) |
9025.000-500 | 05/2000 |
| COBRA Initial Notice Requirements Employers are required to provide a COBRA Initial Notice when employees or their dependent spouses first become covered by a group health plan subject to COBRA. (103KB) In an effort to assist employer groups, HCSC has incorporated this notice into the Certificates of Coverage and Benefit Booklet. Although HCSC has taken this extra step, it is the employer group’s responsibility to make this notice available to each covered employee and to the employee’s spouse (if covered under the plan) not later than the earlier of: Either 90 days from the date on which the covered employee or spouse first becomes covered under the plan; or If later, the date on which the plan first becomes subject to the continuation coverage requirements; or The date on which the administrator is required to furnish an election notice to the employee or to his or her spouse or dependent. |
0009.443 | 08/2004 |
| Continuation of Coverage (COBRA) & COBRA Disability Application for Group Benefit Officers to request continued coverage for employee due to employee's reduction in work hours, retirement, termination, etc. Application includes two sections; Application For COBRA First Qualifying Event and Application for COBRA Second Qualifying Event. (106KB) |
COBRA06, 05253.1106 | 11/2006 |
| Texas Six (6) Month State Continuation of Insurance Application Form (Post COBRA) This application is for members whose 18-month COBRA Continuation Coverage has ended, and who are eligible for an additional six (6) months of Continuation Coverage under Texas law. Use this form if the employer group administers its own COBRA Continuation Coverage. If BCBSTX is the group's COBRA Services administrator, please call 888-541-7107. If an outside Third-Party-Administrator (TPA) administers the group's continuation coverage, please contact the group's TPA. |
53780.1011 | 10/2011 |
| Dependent Addition and Change Form for Court Mandated Health Coverage Use this form for clients who have court mandated health coverage changes. (25KB) |
2849.276 | 01/2004 |
| Dependent State Continuation Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage for up to 36 months from loss of coverage due to divorce, death or retirement of the employee. (38KB) |
StateContDep06, 43942.1106 | 11/2006 |
| Dental Claim Form Members with dental coverage through Blue Cross and Blue Shield of Texas can use this form to file dental claims for reimbursement that are not filed by their providers. (40KB) |
55352.0112 | 01/2012 |
| Texas Nine (9) Month State Continuation of Insurance Application Form This application is for members who are not eligible for COBRA, but have the option to elect nine (9) months of Continuation Coverage under Texas law. Use this form if the employer group administers its own Texas State Continuation of Coverage. If BCBSTX is the group's Texas State Continuation of Coverage administrator, please call 888-541-7107. |
53594.1011 | 10/2011 |
| 2015 Enrollment Application/Change Form (201KB) |
728117.0814 | |
| 2015 Enrollment Application/Change Form — Spanish (206KB) |
726435.0115 | |
| Domestic Partner Affidavit (51KB) Submit a signed, notarized Domestic Partner Affidavit with the signed Enrollment Application/Change form to request dependent coverage for a domestic partner. Note: The employer group must have elected the Domestic Partner Coverage option for domestic partners to be eligible for coverage. |
11/2012 | |
| Away From Home Care Guest Membership Application (for HMO members) HMO members can use this form to apply for guest membership at a Host HMO when residing outside their home plan service area for 90+ consecutive days. Please read and follow the instructions on the form. |
N/A | N/A |
| Medical Claim Form Blue Cross and Blue Shield of Texas members who have PPO, POS or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers. (66KB) |
1081.000-901 | 09/2001 |
| Medical Claim Form — Spanish Version (72KB) |
1081.000-901 | 09/2001 |
| Prescription Drug Claim Blue Cross and Blue Shield of Texas Members with Prescription Drug coverage can use this form to file retail claims that were not filed by the pharmacy. (347KB) |
3272TX | 01/2012 |
| PrimeMail New Prescription Order Form BCBSTX members with Mail Order Prescription Drug coverage can use this form to request a new order for maintenance medications through the mail. (237KB) |
3208TXNEW | 12/2010 |
| PrimeMail Refill Prescription Order Form BCBSTX members with Mail Order Prescription Drug coverage can use this form to request a refill for maintenance medications through the mail. (360KB) |
3208TXREFILL | 12/2010 |
Producer Commission Electronic Funds Transfer Form  Use this form to set up a new electronic funds transfer (EFT) payment program or to change your existing EFT payment program. The form can be mailed or faxed to the Broker Administration Department at Blue Cross and Blue Shield of Texas. Address and fax number are included in the form. (52KB) |
N/A | 04/2012 |
| Proxy Letter Complete by employer so that the HCSC Board of Directors can act on the members' behalf at board meetings. (36KB) |
FC849 | 07/1983 |
| RCI Utilizers Request Form Request form for Legislative Reports for Texas Top Utilizer Reports and Oklahoma Top Claims Report. The form requires the signature to be from someone from the account/group that has appropriate signature authority to receive PHI and can not be signed by the broker/producer. This form is used to request the Top Utilizers report, information pursuant to Texas Insurance Code Sec. 1215.003, which includes a list of claimants for any individual whose total paid claims exceed $15,000 during the 12-month period preceding the date of the report or the entire coverage period, which ever is shorter. (36KB) |
N/A | 03/2011 |
| 2015 Small Employer Benefit Program Application (BPA) (488KB) For new groups with effective dates on and after Jan. 1, 2015. |
TDI# TXBPASG-OFF-EX11.14 | 1/2015 |
| Employer Group Information (EGI) Form (79KB) For Small Employer Groups (2-50) that have reached their 2014 Renewal Dates - Use the EGI form to submit employee counts for COBRA, Medicare Secondary Payor Status and Medical Loss Ratio. |
N/A |
01/2014 |
| 2015 Small Employer Benefit Program Application (Application for Amendment) (327KB) For renewing groups with anniversary dates on and after Jan. 1, 2015. |
TDI# TXBPASG-OFF-EX11.14 | 1/2015 |
| 2014 Small Employer Benefit Program Application (Application for Amendment) (282KB) For existing groups that have not yet reached their 2015 renewal dates. |
TDI# |
11/2013 |
| Small Group Submission Checklist (64KB) |
51362.1212 | 12/2012 |
| Small Group Important Timelines (115KB) |
52687.0110 | 01/2010 |
| Small Group Important Timelines (47KB) Effective Jan. 1, 2014 |
725874.0913 | 01/2014 |
| Student Certification Form (43KB) |
54545.0611 | 06/11 |
| Dependent Student Medical Leave Certification Form (32KB) |
53947.0111 | 01/11 |
| Texas Supplemental Employment Verification Form This form is used by producers when submitting new small groups. it verifies any new employees or owners of the company (50KB) |
N/A | 09/2009 |
| Tips for Submitting New Small Groups Regulated Groups with 2-50 Eligible Employees. (702KB) |
50203.413 | 04/2013 |
| Quote Requests Checklist - Small Groups with 2-50 (for off-exchange plans eff. Jan. 1, 2014) (686KB) |
726016.1013 | 10/2013 |
| Guide for Submitting Small Group Quote Requests Regulated Groups with 2-50 Eligible Employees. (742KB) |
51897.0510 | 05/2010 |
Medicare Secondary Payer Information and Form |
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| Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions (130KB) |
21125.0111 | 01/2011 |
| Information Regarding Medicare Secondary Payer (MSP) Statute (298KB) |
21092.0609 | 01/11 |
| MSP Fact Sheet (389KB) |
56064.0612 | 06/12 |
Under federal law, it is the employer's responsibility to inform its insurer or third-party administrator of proper employee counts for the purpose of determining payment priority between Medicare and another insurer. Employer size, not group health plan size, is used in determining whether the group health plan or Medicare is the primary payer. For more details please see the instructions with the Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions (above). In the absence of employer-provided employee counts, the Center for Medicaid & Medicare Services (CMS) requires that the employer's group health plan coverage be considered primary to Medicare. To comply with this requirement BCBSTX requires employer groups to complete the Annual MSP Employer Acknowledgement Form on a yearly basis. Additional information regarding the MSP statute is available in the document titled Information Regarding the Medicare as Secondary Payer Statute.
