Insurance Forms

BlueCross BlueShield Medical Care Claim Form

BlueCross BlueShield International Medical Claim Form

Dependent Enrollment/Change Form HR 101 –  Used to add or drop dependents from an employee’s/retiree’s coverage. (updated 7/16)

Benefit Change Form HR 105 – Used to make changes to an employee’s benefits. To change health or dental coverage or Flexible Spending Account deductions, this form MUST be completed within 31 days of employment or eligibility for benefits or within 31 days of a Change in Status. (updated11/16)

TAMUS Dependent Child’s Statement of Disability HR 182 (updated 7/13)

Medicare Coordination Acknowledgment Form HR 106 This form should be signed by retiring employees. (updated 11/22)

Retiree Benefit Enrollment Form HR 107 – Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage. (updated  4/16)

Survivor Health/Dental/Vision Continuation Form HR 112  (updated 7/16)

Grandchild Certification Form

Tobacco User Change Form HR 108  (updated 9/12)

Express Scripts
Express Scripts Prescription Drug Program Member Reimbursement (updated 5/14)

Express Scripts Home Delivery Order Form (updated 1/19)

Express Scripts Medicare Part D Claim Form (updated 1/19)

Delta Dental
Delta Dental Group Dental Claim Form

New York Life Long-Term Disability forms
New Yok Life Claim Form

New York Life Physician Statement of Disability