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® . Other Adobe accessibility tools and information can be downloaded at access.adobe.com .

 

INDIVIDUAL FORMS
Stock # / Date Enrollment Forms and Change Forms New Mexico Form #
82798.1015 2016 Application for Individual Medical Plan/Change in Coverage  Use this application for the 2016 plans only, which are effective January 1, 2016. DO NOT use the 2016 application for the 2015 plans. Also DO NOT use the 2015 application for the 2016 plans. N/A
82798.0914 2015 Application for Individual Medical Plan/Change in Coverage  Use this application for the 2015 plans only. DO NOT use the 2015 application for the 2016 plans. N/A
475001.1115 2016 Application for Individual Dental Plan/Change in Coverage  Use this application for the 2016 plans only, which are effective January 1, 2016. DO NOT use the 2016 application for the 2015 plans. Also DO NOT use the 2015 application for the 2016 plans. N/A
475001.1114 2015 Application for Individual Dental Plan/Change in Coverage  Use this application for the 2015 plans only. DO NOT use the 2015 application for the 2016 plans. N/A
42781.0812 Blue Transitions Application  N/A
Stock # / Date Account Maintenance Forms New Mexico Form #
80661.0914 Automatic Premium Payment Authorization Agreement  N/A
Stock # / Date Miscellaneous Forms New Mexico Form #
CS01 10/07 Coordination of Benefits Form  N/A
-- Medicare 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
08.01.15 Standard Authorization Form and other HIPAA Privacy Forms N/A
 

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