{"id":39165,"date":"2024-01-10T09:42:50","date_gmt":"2024-01-10T15:42:50","guid":{"rendered":"https:\/\/www.tamus.edu\/benefits\/?page_id=39165"},"modified":"2025-12-02T08:48:06","modified_gmt":"2025-12-02T14:48:06","slug":"insurance-forms","status":"publish","type":"page","link":"https:\/\/www.tamus.edu\/benefits\/insurance-forms\/","title":{"rendered":"Insurance Forms"},"content":{"rendered":"<p><strong>Benefit Forms<\/strong><\/p>\n<ul>\n<li><a title=\"Claim Form\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/medical_claim_tx_2016.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">BlueCross BlueShield Medical Care Claim Form<\/a><\/li>\n<li><a title=\"BlueCross BlueShield International Claim Form \" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/Internationalclaimform.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">BlueCross BlueShield International Medical Claim Form<\/a><\/li>\n<li><a title=\"Dependent Enrollment Form\/Certification\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/101new.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Dependent Enrollment\/Change Form HR 101<\/a> \u2013\u00a0 add or drop dependents from an employee\u2019s\/retiree\u2019s coverage. (updated 7\/16)<\/li>\n<li><a title=\"TAMUS Dependent Child's Statement of Disability\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/\/pdf\/publications\/forms\/182.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">TAMUS Dependent Child\u2019s Statement of Disability HR 182<\/a>\u00a0(updated 7\/13)<\/li>\n<li><a title=\"Medicare Coordination Acknowledgment Form\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/106.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Medicare Coordination Acknowledgment Form HR 106<\/a>\u00a0This form should be signed by retiring employees. (updated 11\/22)<\/li>\n<li><a title=\"Retiree Benefit Enrollment Form\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/\/pdf\/publications\/forms\/107new.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Retiree Benefit Enrollment Form HR 107<\/a>\u00a0\u2013 Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage. (updated\u00a0 4\/16)<\/li>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/website\/Forms\/HR112.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Survivor Health\/Dental\/Vision Continuation Form HR 112<\/a>\u00a0 (updated 9\/25)<\/li>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/protected\/forms\/GrandchildCertificationForm.pdf\">Grandchild Certification Form HR 120<\/a>\u00a0 (updated 9\/19)<\/li>\n<li><a title=\"Tobacco User Change Form \" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/\/pdf\/publications\/forms\/108new.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Tobacco User Change Form HR 108\u00a0\u00a0<\/a>(updated 9\/12)<\/li>\n<\/ul>\n<p><strong>Express Scripts<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/expressscriptsdirectclaimform.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Express Scripts Prescription Drug Program Member Reimbursement<\/a> (updated 5\/14)<\/li>\n<li><a style=\"font-size: revert\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/expressscriptshomedelivery.pdf\">Express Scripts Home Delivery Order Form<\/a><span style=\"font-size: revert\">\u00a0(updated 1\/19)<\/span><\/li>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/pdf\/publications\/forms\/ESIMedicarePartDClaim.pdf\">Express Scripts Medicare Part D Claim Form<\/a>\u00a0(updated 1\/19)<\/li>\n<\/ul>\n<p><strong>Delta Dental<\/strong><\/p>\n<ul>\n<li><a title=\"Delta Dental Group Dental Claim Form\" href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/\/pdf\/publications\/forms\/claimform_ddic.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Delta Dental Group Dental Claim Form<\/a><\/li>\n<\/ul>\n<p><strong>New York Life Long-Term Disability forms<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/website\/NYL_LTDClaimForm.pdf\">New York Life Claim Form<\/a><\/li>\n<li><a href=\"https:\/\/assets.system.tamus.edu\/files\/benefits\/website\/NYLStatement.pdf\">New York Life Physician Statement of Disability<\/a><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Benefit Forms BlueCross BlueShield Medical Care Claim Form BlueCross BlueShield International Medical Claim Form Dependent Enrollment\/Change Form HR 101 \u2013\u00a0 add or drop dependents from an employee\u2019s\/retiree\u2019s coverage. (updated 7\/16) TAMUS Dependent Child\u2019s Statement of Disability HR 182\u00a0(updated 7\/13) Medicare Coordination Acknowledgment Form HR 106\u00a0This form should be signed by retiring employees. (updated 11\/22) Retiree&#8230;<\/p>\n","protected":false},"author":1971,"featured_media":0,"parent":0,"menu_order":6,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","_kad_blocks_custom_css":"","_kad_blocks_head_custom_js":"","_kad_blocks_body_custom_js":"","_kad_blocks_footer_custom_js":"","_kadence_starter_templates_imported_post":false,"_kad_post_transparent":"default","_kad_post_title":"default","_kad_post_layout":"default","_kad_post_sidebar_id":"","_kad_post_content_style":"default","_kad_post_vertical_padding":"default","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","footnotes":""},"class_list":["post-39165","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Insurance Forms - Benefits<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.tamus.edu\/benefits\/insurance-forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Insurance Forms - Benefits\" \/>\n<meta property=\"og:description\" content=\"Benefit Forms BlueCross BlueShield Medical Care Claim Form BlueCross BlueShield International Medical Claim Form Dependent Enrollment\/Change Form HR 101 \u2013\u00a0 add or drop dependents from an employee\u2019s\/retiree\u2019s coverage. (updated 7\/16) TAMUS Dependent Child\u2019s Statement of Disability HR 182\u00a0(updated 7\/13) Medicare Coordination Acknowledgment Form HR 106\u00a0This form should be signed by retiring employees. 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