Member

Downloadable Forms

Our most frequently requested forms are available as PDF files. Just click on the appropriate form, print the form, fill it out, and mail it in. You will need the Adobe® Reader® to view the following forms; download it free of charge from Adobe's site.

Enrollment/Change Forms

Application for Blue Transitions Temporary Individual Coverage

English Adobe Acrobat PDF

Application for Individual Medical Insurance with Option for Term Life and Dental Insurance
(for BlueDirect and BlueEdge Individual HSA Plans)

English Adobe Acrobat PDF  Spanish Adobe Acrobat PDF

Application for Medicare Supplement Policies

English Adobe Acrobat PDF

Group Enrollment/Change Application

English Adobe Acrobat PDF  Spanish Adobe Acrobat PDF

Dental Enrollment Application/Change Form for Groups

English Adobe Acrobat PDF

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

English Adobe Acrobat PDF

Student Certification Form

English Adobe Acrobat PDF

Request for Coverage for Mentally or Physically Impaired Dependents

English Adobe Acrobat PDF

Application for a Transfer of Coverage — Use this form to transfer a spouse to his/her own policy in the event of divorce or death of the Primary Insured, transfer a dependent reaching the limiting age of 25 to his/her own policy, or make a change (e.g., increase policy deductible level) to reduce the premium.
(for BlueDirect, BlueChoice, BlueChoice Plus, and BlueEdge Individual HSA Plans)

English Adobe Acrobat PDF

Account Maintenance Forms

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

English Adobe Acrobat PDF

Medicare Supplement Payment Option Authorization Form

English Adobe Acrobat PDF

Automatic Pay Form
(for members with NMMIP coverage)

English Adobe Acrobat PDF

Claim/Mail-Order Forms

Standard Claim Form

English Adobe Acrobat PDF

BlueCard Worldwide® International Claim Form

English Adobe Acrobat PDF

Dental Claim Form

English Adobe Acrobat PDF

Vision Claim Form

English Adobe Acrobat PDF

Prescription Drug Claim Form

English Adobe Acrobat PDF

PrimeMail Prescription Drug Mail-Order Form

English Adobe Acrobat PDF  Spanish Adobe Acrobat PDF

Coordination of Benefits Forms

Coordination of Benefits Form

English Adobe Acrobat PDF

Medicare Coordination of Benefits Form

English Adobe Acrobat PDF

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 Adobe Acrobat PDF

Standard Authorization Form and other HIPAA Privacy Forms

See Web Page Go to Web Page

Appeal Request Form

English Adobe Acrobat PDF

 

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