These forms are available as PDF files. Just click on a form, print the form, and fill it out. You will need Adobe® Reader® to view the following forms; this can be downloaded free of charge at Adobe's site.
- Primary Care Provider Selection Form – BlueSalud members must select a PCP. Fill in your PCP's information, and mail the completed form to BCBSNM.
English
Spanish - Health Status Questionnaire for Adult – Mail the completed form to: Blue Cross and Blue Shield of New Mexico, P.O. Box 27838, Albuquerque, NM 87125-9705.
English Spanish - Health Status Questionnaire for Child – Mail the completed form to: Blue Cross and Blue Shield of New Mexico, P.O. Box 27838, Albuquerque, NM 87125-9705.
English Spanish - BlueSalud Free Infant Car Seat Program – English/Spanish
- Patient Medication List Form – Keep a record of your medications on hand to share with your doctor.
English Spanish - PrimeMail Rx Drugs Mail Order Form – English Spanish
- PrimeMail Rx Mail-Order Flyer – English Spanish
- Medicaid Prescription Drug Claim Form
- Transportation – Mileage Reimbursement Form
Also see Guidelines for Mileage Reimbursement - Transportation – Meals and Lodging Expense Report Form
Also see Guidelines for Meals and Lodging Reimbursement - Power of Attorney Form – Designate someone you trust to make health care decisions if you are unable to do so. Follow instructions on the form.
- Standard Authorization Form and other HIPAA Privacy Forms
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