Employer Offered Coverage Information and Forms

Get the most from your Employer Offered health insurance coverage by using these helpful forms and documents to make plan changes, add features and learn about other important ways to help manage your account.

These forms are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe^® Reader^® to access these files, which you can download for free at Adobe's site. 

Note: If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of Texas.

HMO Members Rights and Responsibilities

Employer Offered Coverage Forms to Return to HR

Photocopy and return these completed forms to your employer's human resource department. Keep a copy for your records.

• Group Enrollment Application/Change Form —Form No. EE/CHG5 0807
  Existing Blue Cross and Blue Shield of Texas group members must use this form to submit changes to their coverage or personal information such as: a name or address change, to add or drop dependents, or a change to their PCP election. New group members must use this form when enrolling in a Blue Cross and Blue Shield of Texas group product offered by their employer.
• Formulario de cambios de información/Solicitud de inscripción grupal —Forma de la Politica EE/CHG5-SP 0807. Same instructions as stated above for existing and new group members
• Student Dependent Certification This form is being revised. Members may call the number on the back of their identification cards to update or discuss dependents' student status.
• Change Life Beneficiary  Members who have life coverage through Group Life and Health/Dearborn National can use this form to change beneficiaries on their life policies.
Policy form R2 X6053
• Dependent Child Statement of Disability  Policy form Disability02 2487.000-202
• Dependent State Continuation  Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage of their current benefits for up to 36 months if coverage is loss due to divorce, death or retirement of the employee. Policy form StateContDep06 43942.1106

Employer Offered Coverage Forms to Return to BCBSTX

Photocopy and return these completed claims forms to Blue Cross and Blue Shield of Texas. Keep a copy for your records.

• Medical Claim Form   Blue Cross and Blue Shield of Texas members who have PPO, or traditional indemnity coverage can use this form to file claims for reimbursement that are not filed by their providers. Policy form 1081.000-901
• Medical Claim Form - Spanish Version   Forma de la Politica 1081.000-901 SP
• HMO Blue^® Texas Medical Claim Form   HMO Blue^® Texas members can use this form to file claims for reimbursement that are not filed by their providers. Policy form MBRCLM102 8708.995-102
• Dental Claim Form   Members with dental coverage through Blue Cross and Blue Shield of Texas can use this form to file dental claims for reimbursement that are not filed by their providers.
• Standard Authorization Form to Use or Disclose Protected Health Information (PHI)   This form should be used only by members who have a group health insurance policy through their employer.