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