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        About the Pool

Texas Health Insurance  Pool
Claim, Change & Other Forms

For the convenience of our members, the Pool´s medical claim and prescription claim forms are provided below in a downloadable Adobe Reader file. These claim forms are used only if your physician does not file your medical claim directly with the Pool or if you fill a prescription without using your drug card.   The Pool’s Change Form is also provided below. This form is used to: report changes of address, increase deductible plan, cancel coverage, change smoker status, or change payment method. You may use the Additional Enrollment Form to request coverage for a qualified family member or dependent.

Please note that documents in Adobe Reader (pdf format) require a recent version of the free software.  Use the following link  to download: Adobe Reader Claim Forms Medical  Claim Form Medco Health Solutions Prescription Claim Form  (for other prescription benefit forms, open the Pharmacy Program link) Enrollment/Membership Continued Eligibility Verification Form (OGE) Self-Employment Verification Form (#SEVF)   Employer Verification  Form (#EVF)    Change Form  Additional Enrollment Form Appeal Forms Pre-Existing Condition Drug Investigation Form   Grievance Procedure Form- Pharmacy (Medco Health Solutions)  (for other prescription benefit forms, open the Pharmacy Program link) Grievance Procedure Form- (All Other Appeals) Other Forms Financial Information Privacy Notice HIPAA Notice of Privacy Practices Standard Authorization Form to Disclose Protected Health Information ("PHI") Medical Services Predetermination Form--ParPlan/BlueChoice® Providers Please note that documents in Adobe Reader (pdf format) require a recent version of the free software.  Use the following link  to download: Adobe Reader Return to Top