| Applications and/or Miscellaneous Change Forms |
Form # |
Revision Date |
Non-Underwritten Changes Miscellaneous Change Form This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage and Select 2000) and non-Series III Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits. (69 KB)
|
IND-MCF-Non-UW-1 |
06/07 |
Underwritten Changes Miscellaneous Change Form This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits. (108 KB)
|
IND-MCF-UW-1 |
06/07 |
BlueEdge Individual HSA Application/Miscellaneous Change Form (76 KB)
|
BLUE EDGE-IND-HSA-APP/MCF-2 |
04/07 |
| BlueEdge Individual HSA Special Offer Application This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. (58 KB) |
BLUE EDGE-IND-HSA-APP(SO) |
05/06 |
| Application/Miscellaneous Change Form for Foundation Hospital Care (73 kb) |
PPO-IN HOSPITAL-APP/MCF |
04/07 |
| MSA Blue Application/Miscellaneous Change Form (75 KB) |
IND-CMM-APP/MCF |
01/07 |
| PPO Select Basic Application (87 KB) |
PPO-IND-CCHBP-App.(B)-2 |
04/07 |
PPO Select Basic Miscellaneous Change Form (70 KB)
|
PPO-IND-CCHBP-MCF(B)-2 |
01/07 |
| PPO Select Value Care Application/Miscellaneous Change Form (175 KB) |
PPO-IND-VALUE-APP/MCF-1 |
04/07 |
| PPO Select Value Care (Formulario de cambios de informacion de la solicitud/general para cobertura individual) This is the Spanish version of the PPO Select Value Care Application/Miscellaneous Change Form. (175 KB) |
FORMULARIO NRO.PPO-IND-VALUE-APP/MCF-1 |
04/07 |
| SelecTEMP PPO Temporary Individual Coverage Application (76 KB) |
PPO-STM-3-APP |
11/07 |
| Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) (69 KB) |
IND-APP/MCF-1 |
04/07 |
Special Offer Application (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application.
(62 KB) |
IND-APP(SO) |
02/06 |
| Solicitud/Formulario de cambios miscellaneous This is the Spanish version of the Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver - Series III) |
IND-APP/MCF-1 |
01/06 |
| General Miscellaneous Forms |
Form # |
Revision Date |
| Automatic Premium Payment Authorization Agreement Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. (38 KB) |
8708.558.1007 |
10/07 |
| Acuerdo de autorizacion para el pago de prima automatico This is the Spanish version of the Automatic Premium Payment Authorization Agreement. Complete and mail or fax this form to get the proper authorization for monthly premium bank drafts. (37 KB) |
49218.1007 |
10/07 |
| Blue HealthCare Bank (BHB) Sales Pack The BHB Sales Pack includes information on the following: About Health Savings Accounts – HSAs; Enrollment Instructions; Interest Rates & Fee Schedule; HSA Application; HSA Deposit Account Agreement and Privacy Policy & Practices. |
N/A |
10/08 |
| Continuation of Coverage Request Form Use this form to continue existing coverage for dependents when membership is affected by divorce, death, or other qualifying events. (17 KB) |
47133.1206 |
12/06 |
| Mail Order Form - Prime Mail Pharmacy (137 KB) |
40690-1005 |
10/05 |
| Medical Claim Form (18 KB) |
1081.000.901 |
09/01 |
| Medical Claim Form - Spanish Version (72 KB) |
1081.000.901 |
09/01 |
| Prescription Reimbursement 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. (146 KB) |
40959-704 |
07/04 |
| Standard Authorization to Use or Disclose Protected Health Information (PHI) This form should be used only by members who have an Individual health insurance policy. |
N/A |
09/07 |
