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 |
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Group Master Contract Provisions for BCBSNM Products |
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Group Master Contract Provisions for HMO Products |
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Group Master Application |
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Group Proxy Form |
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Enrollment/Change Forms |
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Group Enrollment/Change Application |
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Application for Blue Transitions Temporary Individual Coverage |
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Dental Enrollment Application/Change Form for Groups |
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Away From Home Care® Guest Membership Application — for HMO members only |
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Dependent Student Medical Leave Certification Form |
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Student Certification Form |
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Request for Coverage for Mentally or Physically Impaired Dependents |
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Group Employee Termination Form |
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Insurance Waiver |
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Employee Medical Disclosure Statement for group sizes 51+ |
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Claim/Mail-Order Forms |
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Standard Claim Form |
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BlueCard Worldwide® International Claim Form |
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Dental Claim Form |
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Vision Claim Form |
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Prescription Drug Claim Form |
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PrimeMail Prescription Drug Mail-Order Form |
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Coordination of Benefits Forms |
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Coordination of Benefits Form |
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Medicare Coordination of Benefits Form |
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Medicare Secondary Payer (MSP) Information and Form |
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Information Regarding the Medicare as Secondary Payer Statute |
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Instructions — Completing the Annual MSP Employer Acknowledgement Form |
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BCBSNM Annual MSP Employer Acknowledgement Form |
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Legal/HIPAA Privacy Forms |
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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. |
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Standard Authorization Form and other HIPAA Privacy Forms |
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