Downloadable Forms for NMSU Medicare Carveout Plan

The following forms are available to print, fill out, and fax or mail to BCBSNM. They are provided as PDF files. If you do not have Adobe® Reader®, download it free of charge at Adobe's site.

• Standard Claim Form 

• Request for Coverage for Mentally or Physically Impaired Dependents 

• Coordination of Benefits Form 

• Medicare Coordination of Benefits Form 

• 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

Learn More About NMSU Medicare Carveout Plan:
Benefit Information
FAQs
Provider Information

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