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 – Blue Cross Community Centennial Members must select a PCP. Fill in your PCP's information and mail the completed form to BCBSNM.
- Blue Cross Community Centennial Free Infant Car Seat and Crib Program – Use this form to write down your doctor visits. Have your doctor sign it with each visit. Follow the instructions on the form before sending it to BCBSNM.
- Patient Medication List Form – Keep a record of your medications on hand to share with your doctor.
- PrimeMail New Prescription Order Form – Use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail, and include the original prescription signed by your doctor.
- PrimeMail Refill Prescription Order Form – Use this form to mail order refills for prescribed maintenance medication.
- PrimeMail Rx Mail-Order Flyer - You can order the medicines that you take long-term or every day from home and have them delivered.
- Medicaid Prescription Drug Claim Form – Use this form to submit a claim for a prescription.
- 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 – Have 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