Texas Health Insurance Risk 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.

If you have any questions concerning your claims or the change form, please contact the Pool´s Administrator at 1-888-398-3927 (TDD: 1-800-735-2988).

Claims Forms

• Medical  Claim Form (pdf format)
  
• Medco Health Solutions Prescription Claim Form 
  for fill dates beginning 01-01-2007 (pdf format)
  
• WellPoint Prescription Claim Form
  for fill dates ending 12-31-2006 (pdf format)
  
  

Enrollment/Membership

• Annual Eligibility Verification Form   (pdf format)
• Self-Employment Verification Form (#SEVF)  (pdf format)
• Employer Verification  Form (#EVF)   (pdf format)
• Change Form (pdf format) 
• Additional Enrollment Form (pdf format)

Appeal Forms

• Pre-Existing Condition Drug Investigation Form   (pdf format)
  
• Grievance Procedure Form- Pharmacy (Medco Health Solutions)  
  Effective 01-01-2007) (pdf format)
  
• Grievance Procedure Form- All Other Appeals (pdf format)

Other Forms

• Financial Information Privacy Notice (pdf format)
  
• HIPAA Notice of Privacy Practices (pdf format)
• Standard Authorization Form to Disclose Protected Health Information ("PHI") (pdf format)
  
  
  
  
  
  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

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