Blue Access for Producers

Downloadable Forms for Mid-Market 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 NameDigital FormDownload

2021/2022 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

2021/2022 Group Enrollment Application/Change Form – Spanish

N/A download form Acrobat PDF

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

N/A download form Acrobat PDF
download form Word Document

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

N/A download form Word Document

Benefit Program Application (BPA) for HCA Insured Group Plans

N/A download form Acrobat PDF
download form Word Document

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

sign now External Link 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

sign now External Link download form Acrobat PDF

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

Group Enrollment Template Spreadsheet

N/A download form Acrobat PDF

Group Proxy Letter/Form – included in BPA

N/A download form Acrobat PDF

RCI Utilizers Request Form

N/A download form Acrobat PDF
download form Word Document

Student Certification Form

N/A download form Acrobat PDF

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

sign now External Link download form Acrobat PDF

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

N/A download form Acrobat PDF

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

N/A N/A

Mid-Market Request for Proposal Form

N/A download form Acrobat PDF

Mid-Market Request for Proposal Checklist

N/A download form Acrobat PDF
download form Word Document

Mid-Market Quote Request Checklist

N/A download form Acrobat PDF

 

Claim Forms and Order Forms

Form NameDigital FormDownload

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 (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.

N/A download form Acrobat PDF

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.

N/A download form Acrobat PDF

 

Miscellaneous Forms

Form NameDigital FormDownload

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 NameDigital FormDownload

Annual MSP Employer Acknowledgement Form with Instructions

sign now External Link 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 NameDigital FormDownload

Standard Authorization Form and other HIPAA Privacy Forms

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N/A

 

 

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