Blue Access for Producers

Downloadable Forms for Mid-Market Group 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).

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MID-MARKET (NRSG) GROUP FORMS (Groups of 51-100)
These downloadable forms are for use with non-regulated small group products.
Stock # / Date Enrollment Forms and Change Forms New Mexico Form #
NM-LG-HP-(Standard)-BPA 2016 Benefit Program Application (BPA) for Groups 51-100  – for new accounts effective on or after 1/1/2016 N/A
477868.1115 2016 Group Enrollment Application/Change Form  – use this form to apply for group coverage or to make changes to an existing BCBSNM policy N/A
NM81797 DP Affidavit Affidavit of Domestic Partnership  N/A
H374 Away From Home Care Guest Membership Application  N/A
M469 9/07 Disabled Dependent Certification Form  N/A
NM81797 Term Statement Statement of Termination of Domestic Partnership  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 Medicare Secondary Payer (MSP) Form and Information New Mexico Form #
21127.0913 Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form  N/A
21093.0609 Information Regarding the Medicare as Secondary Payer Statute  N/A
82284.0612 MSP Fact Sheet  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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