Click on any of the links below to view and print these documents:
Group Contracts and Applications
- Group Master Contract Provisions for BCBSNM Products (PDF)
- Group Master Contract Provisions for HMO Products (PDF)
- Group Master Application (PDF)
- Group Proxy Form (PDF)
Enrollment/Change Forms
- Group Enrollment/Change Application (PDF) — English
- Group Enrollment/Change Application (PDF) — Spanish
- Application for Blue Transitions Temporary Individual Coverage (PDF)
- Dental Enrollment Application/Change Form (PDF)
- Away From Home Care® Guest Membership Application (PDF) — for HMO members only
- Student Certification Form (PDF)
- Request for Coverage for Mentally or Physically Impaired Dependents (PDF)
- Group Employee Termination Form (PDF)
- Insurance Waiver (PDF) — English
- Insurance Waiver (PDF) — Spanish
- Employee Medical Disclosure Statement for group sizes 51+ (PDF) — English
- Employee Medical Disclosure Statement for group sizes 51+ (PDF) — Spanish
- Standard Claim Form (PDF)
- BlueCard Worldwide® International Claim Form (PDF)
- Dental Claim Form (PDF)
- Vision Claim Form - Davis Vision (PDF)
- Vision Claim Form - EyeMed (PDF) – Use this form only for out-of-network vision claims through June 30, 2007
- Prescription Drug Claim Form (PDF)
- PrimeMail Prescription Drug Mail-Order Form (PDF) — English
- PrimeMail Prescription Drug Mail-Order Form (PDF) — Spanish
Coordination of Benefits Forms
Medicare Secondary Payer (MSP) Information and Form
- Information Regarding the Medicare as Secondary Payer Statute (PDF)
- Instructions - Completing the Annual MSP Employer Acknowledgement Form (PDF)
- BCBSNM Annual MSP Employer Acknowledgement Form (PDF)
Legal/HIPAA Privacy Forms
- Power of Attorney for Health Care Form (PDF) — 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
