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 | |
|
Application for Blue Transitions Temporary Individual Coverage |
|
|
Application for Individual Medical Insurance and Dental Insurance (for BlueDirect and BlueEdge Individual HSA Plans) |
|
|
Change Form for BlueChoice and BlueChoice Plus Plans |
|
|
Application for Medicare Supplement Insurance Coverage (Underwritten) |
|
|
Group Enrollment Application/Change Form |
|
|
Away From Home Care® Guest Membership Application (for HMO members only) |
|
|
Student Certification Form |
|
|
Dependent Student Medical Leave Certification Form |
|
|
Request for Coverage for Mentally or Physically Impaired Dependents |
|
| Account Maintenance Forms | |
|
Automatic Premium Payment Authorization Agreement (for members with Blue Transitions, BlueDirect, BlueChoice, BlueChoice Plus, Number One, and NM Major Med) |
|
|
Medicare Supplement Payment Option Authorization Form |
|
|
Automatic Pay Form (for members with NMMIP coverage) |
|
| Claim/Mail-Order Forms | |
|
Medical Claim Form |
|
|
BlueCard Worldwide® International Claim Form |
|
|
Dental Claim Form |
|
|
Vision Claim Form |
|
|
Prescription Drug Claim Form |
|
|
PrimeMail New Prescription Order Form |
|
|
PrimeMail Refill Prescription Order Form |
|
| Coordination of Benefits Forms | |
|
Coordination of Benefits Form |
|
|
Medicare Coordination of Benefits Form |
|
| 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. |
|
|
Standard Authorization Form and other HIPAA Privacy Forms |
|
|
Appeal Request Form |
|
| Other Miscellaneous Forms | |
|
Dental Provider Nomination Form |
|
