Downloadable Forms for Mid-Market Group Products

2021/2022 Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSTX policy

2021/2022 Group Enrollment Application/Change Form – Spanish

2021 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new accounts effective 1/1/21 and after

2021 Benefit Program Application (BPA) Volume-based Discount for Mid-Market Groups 51-150 – for new accounts effective on or after 1/1/21; includes Proxy and Employer Group Information (EGI) form

Benefit Program Application (BPA) for HCA Insured Group Plans

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

Affidavit of Domestic Partnership

Affidavit of Domestic Partnership – Spanish

COBRA Continuation of Coverage Application & Social Security Disability Form

COBRA Initial Notice Requirements

Dependent Addition and Change Form for Court-Mandated Health Coverage

Dependent State Continuation of Coverage Form

Dependent Student Medical Leave Form

Dependent Student Medical Leave Form – Spanish

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).

Group Enrollment Template Spreadsheet

Group Proxy Letter/Form – included in BPA

RCI Utilizers Request Form

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

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

Mid-Market Request for Proposal Form

Mid-Market Request for Proposal Checklist

Mid-Market Quote Request Checklist

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

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.

Medical Claim Form (Domestic) – Spanish

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.

Medical Claim Form (International) – Spanish

Prescription Drug Claim Form (Prime Therapeutics) – Members with pharmacy benefits through BCBSTX can use this Prime Therapeutics claim form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed 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.

Dental Provider Nomination Form

Group Profile Update Form

Producer Commission Electronic Funds Transfer Form

Annual MSP Employer Acknowledgement Form with Instructions

Information Regarding MSP Statute

MSP Fact Sheet

Standard Authorization Form and other HIPAA Privacy Forms

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