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).
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 .
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 #|
|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|
|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|
|81809.0814||2015 Group Enrollment Application/Change Form — Use this form to apply for group coverage or to make changes to an existing BCBSNM policy; for groups enrolling/renewing on or after 1/1/2015.||N/A|
|475811.0115||2015 Group Enrollment Application/Change Form — Spanish —Use this form to apply for small group coverage or to make changes to an existing BCBSNM policy; for groups enrolling/renewing on or after 1/1/2015.||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|