Medical Claim Form (PDF, 69 kB) -
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.

Student Certification Form (PDF, 39 kB) -
To continue coverage beyond the maximum age limit specified in your contract for dependents, this form must be received within 60 days of the affected dependent becoming eligible for coverage as a student dependent."

Dental Form (PDF, 1.29 MB) -
Trisurant Dental Insurance members can use this form to file claims for reimbursements that are not filed by their providers

What is a Coordination of Benefits questionnaire and why do I need to complete one?
If you or your dependents are covered under more than one group medical plan, the plans will work together to coordinate the benefits you receive. To determine if Coordination of Benefits is available and appropriate, we require you complete a Coordination of Benefits questionnaire annually.

When do I need to submit a claim form?
When receiving in-network care, there is usually no need to fill out a claim form. All you need to do is show your ID card to receive benefits. Your doctor or hospital will file claims directly with your healthplan. For some out-of-network care, you may need to fill out a claim form.

Will I be notified when you receive the Coordination of Benefits questionnaire I filled out online?
You will be notified by telephone only if we need additional information from you.