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Blue Access for Members and quoting tools will be unavailable from 2am - 5am on Saturday, October 20.

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Downloadable Forms

Get the most from your health insurance coverage by using these helpful forms and documents to make plan changes, add features, file claims and much more.

Note: Forms on this page are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site  .  If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of New Mexico.


Enrollment/Change Forms

2014 New Mexico Individual Product Under 65 Off Exchange Medical Application or Change in Coverage

English   Spanish 

Application for Blue Transitions Temporary Individual Coverage

English 

Application for Individual Medical Insurance and Dental Insurance (for BlueDirect and BlueEdge Individual HSA Plans)

English   Spanish 

Change Form for BlueChoice and BlueChoice Plus Plans

English 

Application for Medicare Supplement Insurance Coverage (Underwritten)

English 

Group Enrollment Application/Change Form

English   Spanish 

Away From Home Care® Guest Membership Application (for HMO members only)

English 

Student Certification Form

English 

Dependent Student Medical Leave Certification Form

English 

Request for Coverage for Mentally or Physically Impaired Dependents

English 

Account Maintenance Forms

Automatic Premium Payment Authorization Agreement (for members with Blue Transitions, BlueDirect, BlueChoice, BlueChoice Plus, Number One, and NM Major Med)

English 

Medicare Supplement Payment Option Authorization Form

English 

Automatic Pay Form (for members with NMMIP coverage)

English 

Claim/Mail-Order Forms

Medical Claim Form

English 

BlueCard Worldwide® International Claim Form

English 

Dental Claim Form

English 

Vision Claim Form

English 

Prescription Drug Claim Form

English 

PrimeMail New Prescription Order Form

English 

PrimeMail Refill Prescription Order Form

English 

Coordination of Benefits Forms

Coordination of Benefits Form

English 

Medicare Coordination of Benefits Form

English 

Legal/HIPAA Privacy Forms

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.

English 

Standard Authorization Form and other HIPAA Privacy Forms

See Web Page

Appeal Request Form

English 

Other Miscellaneous Forms

Dental Provider Nomination Form

English 


Blue Access for Members