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        About the Pool

Texas Health Insurance  Pool
Claim & Change 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 Medical Services Predetermination Form--ParPlan/BlueChoice® Providers 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") 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