Here are some commonly used forms for enrolling and maintaining your employer group coverage with Blue Cross and Blue Shield of New Mexico (BCBSNM).
To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.
| Form Name | Digital Form | Download |
|---|---|---|
| Group Enrollment Application/Change Form – use this form to apply for group coverage or make changes to an existing BCBSNM policy | N/A | download form |
| Group Enrollment Application/Change Form – Spanish | N/A | download form |
| 2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new and renewing Mid-Market Group accounts effective 7/1/24-12/31/24 | N/A | download form |
| 2024 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new and renewing Mid-Market Group accounts effective 1/1/24-6/30/24 | N/A | download form |
| Employer Group Information (EGI) Form | sign now | download form |
| Affidavit of Domestic Partnership | sign now | download form |
| Away From Home Care Guest Membership Application | N/A | download form |
| Dependent Student Medical Leave Certification Form | N/A | download form |
| Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSNM (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application). | N/A | download form |
| Statement of Termination of Domestic Partnership | N/A | download form |
| Form Name | Digital Form | Download | |
|---|---|---|---|
| 2024–2025 Important Benefit Changes/Uniform Modification Notice – Identifies some of the most important benefit plan changes for the 2024–2025 coverage year. | N/A | download notice | |
| Medical Loss Ratio (MLR) Written Assurance Form – Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. | sign now | download form | |
| Average Employee Count (AEC) Form | sign now | download form |
| Form Name | Digital Form | Download |
|---|---|---|
| Annual MSP Employer Acknowledgement Form (EAF) with Instructions on Completing the Form | sign now | download form |
| Information Regarding the MSP Statute | N/A | download flyer |
| MSP Fact Sheet | N/A | download fact sheet |
| Form Name | Digital Form | Download |
|---|---|---|
| Coordination of Benefits Form | N/A | download form |
| Producer of Record Transfer Form | N/A | download form |
| Medicare Coordination of Benefits Form | N/A | download form |
| Form Name | Digital Form | Download |
|---|---|---|
| Power of Attorney for Health Care – Members can designate someone they trust to make health care decisions if they are unable to do so. Follow instructions on the form. | N/A | download form |
| Power of Attorney for Health Care – Spanish | N/A | download form |
| Standard Authorization Form and other HIPAA Privacy Forms | N/A | access forms |
