Blue Access for Producers

Downloadable Forms for Individual Products


Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of New Mexico (BCBSNM). To access more downloadable forms, please log in to Blue Access for Producers (BAP).

The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

 

2015 Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms New Mexico Form #
82798.0914 Health Application/Change in Coverage  Use this application for the 2015 plans, which are effective January 1, 2015. DO NOT use the 2015 application for the 2014 plans. Also, DO NOT use the 2014 application for the 2015 plans. N/A


2014 Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms New Mexico Form #
475001.0613 Application for Individual Dental Plan/Change in Coverage  N/A
82798.1013 Application for Individual Medical Plan/Change in Coverage  N/A
81.0812 Application for Individual Temporary Insurance Coverage  N/A
Stock # / Date Account Maintenance Forms New Mexico Form #
80661.0713 Automated Premium Payment Authorization Agreement  N/A
Stock # / Date Miscellaneous Forms New Mexico Form #
CS01 10/07 Coordination of Benefits Form  N/A
Stock # / Date Legal / HIPAA Forms New Mexico Form #
-- Power of Attorney for Health Care  Members can designate someone they trust to make health care decisions if they are unable to do so. Follow instructions on the form. N/A
09.01.13 Standard Authorization Form and other HIPAA Privacy Forms N/A

Pre-ACA INDIVIDUAL FORMS
Stock # / Date Enrollment Forms and Change Forms New Mexico Form #
81509.0113 Application for Individual Medical and Dental Insurance Coverage  N/A
2206.0113 Application for Individual Medical and Dental Insurance Coverage - Spanish  N/A
81.0812 Application for Individual Temporary Insurance Coverage  N/A
Stock # / Date Account Maintenance Forms New Mexico Form #
M574 10.07 Automatic Pay Form  - for members with NMMIP N/A
80661.0711 Automatic Premium Payment Authorization Agreement  - for members with Blue Transitions, BlueDirect, BlueChoice, BlueChoice Plus, Number One, and NM Major Med N/A
Stock # / Date Legal / HIPAA Forms New Mexico Form #
-- Power of Attorney for Health Care  - Members can designate someone they trust to make health care decisions if they are unable to do so. Follow instructions on the form. N/A
09.01.13 Standard Authorization Form and other HIPAA Privacy Forms N/A
 

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