Texas producer record blue form 2026

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The document is a Producer of Record Transfer Form that allows a policyholder to appoint a new producer of record for their insurance with Blue Cross and Blue Shield of Texas. It grants the appointed producer access to specific Protected Health Information (PHI) related to insurance support functions, while excluding access to claims or medical information, which requires separate authorization. The form must be completed and submitted to the specified address or fax number.

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Click ‘Get Form’ to open the Texas Producer Record Blue Form in the editor.
Begin by entering the effective date in the format MM/DD/YYYY. This indicates when you appoint your new producer of record.
In the next field, write the name of your appointed producer of record. Ensure that this is accurate as they will have access to your Protected Health Information (PHI).
Sign the form in the designated area to confirm your appointment of the producer. Below, print your name clearly for verification.
Fill in your Policy ID Numbers and provide the printed name and ID number of your producer.
Complete the date field and include a reason for your request if applicable. Remember, incomplete forms cannot be processed.
Once completed, save and download your form. You can then return it via mail or fax as specified.

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