Blue Access for Producers

Downloadable Forms for Large Group Products


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

2020/2021 Group Enrollment Application/Change Form – Use this form to apply for group coverage or to make changes to an existing BCBSTX policy

N/A download form Acrobat PDF

2020/2021 Group Enrollment Application/Change Form – Spanish

N/A download form Acrobat PDF

2021 Benefit Program Application (BPA) for Large Groups 151+ – for new accounts effective 1/1/21 and after

N/A download form Word Document
download form Acrobat PDF

2021 Benefit Program Application (BPA) for HCA Insured Group Plans – for new accounts effective 1/1/21 and after

N/A download form Word Document
download form Acrobat PDF

Affidavit of Domestic Partnership

sign now External Link download form Acrobat PDF

Affidavit of Domestic Partnership – Spanish

N/A download form Acrobat PDF

Away From Home Care Guest Membership Application – for HMO members

N/A download form Acrobat PDF

Away From Home Care Guest Membership Application – Spanish – for HMO members

N/A 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

Dependent Addition and Change Form for Court-Mandated Health Coverage

N/A download form Acrobat PDF

Dependent State Continuation of Coverage Form

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Dependent Student Medical Leave Form

N/A download form Acrobat PDF

Dependent Student Medical Leave Form – Spanish

N/A download form Acrobat PDF

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 download form Acrobat PDF

RCI Utilizers Request Form

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

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

N/A 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

N/A download form Acrobat PDF

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.

N/A download form Acrobat PDF

Medical Claim Form (International) – Spanish

N/A download form Acrobat PDF

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 download form Acrobat PDF

PrimeMail Prescription 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

 

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

 

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