Downloadable Forms
Click on any of the links below to view and print these documents. Most of this information is available as PDF files. You will need the Adobe® Reader® to view the following forms; download it free of charge from Adobe's site 
.
Group Contracts and Applications |
|
Group Master Contract Provisions for BCBSNM Products |
|
Group Master Contract Provisions for HMO Products |
|
Group Master Application |
|
Group Proxy Form |
|
Enrollment/Change Forms |
|
Group Enrollment/Change Application |
|
Application for Blue Transitions Temporary Individual Coverage |
|
Dental Enrollment Application/Change Form for Groups |
|
Away From Home Care® Guest Membership Application — for HMO members only |
|
Dependent Student Medical Leave Certification Form |
|
Student Certification Form |
|
Request for Coverage for Mentally or Physically Impaired Dependents |
|
Group Employee Termination Form |
|
Insurance Waiver |
|
Employee Medical Disclosure Statement for group sizes 51+ |
|
Claim/Mail-Order Forms |
|
Standard Claim Form |
|
BlueCard Worldwide® International Claim Form |
|
Dental Claim Form |
|
Vision Claim Form |
|
Prescription Drug Claim Form |
|
PrimeMail Prescription Drug Mail-Order Form |
|
Coordination of Benefits Forms |
|
Coordination of Benefits Form |
|
Medicare Coordination of Benefits Form |
|
Medicare Secondary Payer (MSP) Information and Form |
|
Information Regarding the Medicare as Secondary Payer Statute |
|
Instructions — Completing the Annual MSP Employer Acknowledgement Form |
|
BCBSNM Annual MSP Employer Acknowledgement Form |
|
Legal/HIPAA Privacy Forms |
|
Power of Attorney for Health Care 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 |
|
