Our most frequently requested forms are available in Adobe Acrobat format. Just click on the appropriate form, print the form, fill it out, and mail it in.
You will need the Adobe Acrobat Reader to view the following forms. This can be downloaded free of charge from Adobe's site.
Enrollment/Change Forms
- Application for Blue Transitions Temporary Individual Coverage (PDF)
- Application for Individual Medical Insurance and Term Life Insurance (PDF) — English — for BlueDirect and BlueEdge Individual HSA Plans
- Application for Individual Medical Insurance and Term Life Insurance (PDF) — Spanish — for BlueDirect and BlueEdge Individual HSA Plans
- Application for Individual Medical Insurance and Term Life Insurance (PDF) — for BlueChoice and BlueChoice Plus Plans
- Application for Medicare Supplement Policies (PDF)
- Group Enrollment/Change Application (PDF) — English
- Group Enrollment/Change Application (PDF) — Spanish
- 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)
- Transfer of Coverage Application (PDF) — for BlueDirect, BlueChoice, BlueChoice Plus, and BlueEdge Individual HSA Plans — 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.
Account Maintenance Forms
- Automatic Payment Authorization Form (PDF) — for members with Blue Transitions, BlueDirect, BlueChoice, BlueChoice Plus, Number One, and NM Major Med
- Medicare Supplement Payment Option Authorization Form (PDF)
- Automatic Pay Form (PDF) — for members with NMMIP
Claim/Mail-Order Forms
- Standard Claim Form (PDF)
- BlueCard Worldwide® International Claim Form (PDF 31K)
- 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
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
- Appeal Request Form (PDF)
