Downloadable Forms for Small Group Products

2019 Benefit Program Application (BPA) – for accounts effective 1/1/19 and after

2019 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2019; use this form to amend the original BPA

2018 Benefit Program Application (BPA) for New Small Groups 2-50 – for accounts effective 1/1/18 and after

2018 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2018; use this form to amend the original BPA

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

2017 Composite Billing Guide and FAQs – for new and existing fully insured accounts (up to 50 employees)

2018 Group Enrollment Application/Change Form

2018 Group Enrollment Application/Change Form – Spanish

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

Dependent's Child Statement of Disability Form

Dependent's Child Statement of Disability Form – Spanish

Group Proxy Letter/Form – included in BPA

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

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

Texas Supplemental Employment Verification Form

2019 Benefit Program Application (BPA) Amendment – for renewing accounts with anniversary dates on or after 1/1/2019; use this form to amend the original BPA

2019 Significant Benefit Changes to Select Small Group Plans – for accounts renewing 1/1/19 and after

2019 Small Group Billing Preferences Guide – for accounts effective 1/1/19 and after

2019 HMO Plan Disclosure Notice Form

2018 Group Enrollment Application/Change Form

2018 Group Enrollment Application/Change Form – Spanish

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 – 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.

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.

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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