BlueSalud^SM

Download Forms

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 New Prescription Order Form – English  Spanish 
• PrimeMail Refill Prescription 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