Medicaid Health Insurance Plan
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 – BlueSalud members must select a PCP. Fill in your PCP's information, and mail the completed form to BCBSNM.
- Health Status Questionnaire for Adult – Mail the completed form to: Blue Cross and Blue Shield of New Mexico, P.O. Box 27838, Albuquerque, NM 87125-9705.
- Health Status Questionnaire for Child – Mail the completed form to: Blue Cross and Blue Shield of New Mexico, P.O. Box 27838, Albuquerque, NM 87125-9705.
- BlueSalud Free Infant Car Seat Program – English/Spanish
- Patient Medication List Form– Keep a record of your medications on hand to share with your doctor.
- PrimeMail New Prescription Order Form – English Spanish
- PrimeMail Refill Prescription Order Form – English Spanish
- PrimeMail Rx Mail-Order Flyer – English/Spanish
- Medicaid Prescription Drug Claim Form
- 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 – 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