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Downloadable Forms for Small Group Products (2-50)


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.

To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.


Proposal Forms


Form Name Digital Form Download
Request for Quote Proposal/Census Form (Groups 2-50) N/A download form Acrobat PDF

 

Enrollment Forms and Change Form


Form Name Digital Form Download
Enrollment Package - includes 2016 Benefit Program Application (BPA) for New Small Groups 2-50, Employer Group Information (EGI) Form, and Artifacts Documentation sign now External Link N/A
2016 Benefit Program Application (BPA) for New Small Groups 2-50 - for new accounts effective on or after 1/1/2016 sign now External Link download form Acrobat PDF
New Mexico Universal Application sign now External Link N/A
2016 Benefit Program Application (BPA) Amendment for Small Groups 2-50 - for renewing accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA N/A download form Acrobat PDF
2015 Benefit Program Application (BPA) Amendment for Small Groups 2-50 - for existing accounts enrolled on or after 1/1/2015 but not yet renewed in 2016; use this form to amend the original BPA N/A download form Acrobat PDF
2016 Group Enrollment Application/Change Form - use this form to apply for group coverage or make changes to an existing BCBSNM policy sign now External Link download form Acrobat PDF
Affidavit of Domestic Partnership sign now External Link download form Acrobat PDF
Away From Home Care Guest Membership Application N/A download form Acrobat PDF
Disabled Dependent Certification Form sign now External Link download form Acrobat PDF
2015 Small Group Pediatric Dental Opt-Out Form N/A download form Acrobat PDF
Statement of Termination of Domestic Partnership N/A download form Acrobat PDF

 

Miscellaneous Forms


Form Name Digital Form Download
Coordination of Benefits Form N/A download form Acrobat PDF
Medicare Coordination of Benefits Form N/A download form Acrobat PDF
Student Medical Leave Certification Form N/A download form Acrobat PDF

 

Medicare Secondary Payer (MSP) Form and Information


Form Name Digital Form Download
Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form N/A download form Acrobat PDF
Information Regarding the Medicare as Secondary Payer Statute N/A download form Acrobat PDF
MSP Fact Sheet N/A download form Acrobat PDF

 

Legal / HIPAA Forms


Form Name Digital Form Download
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 download form Acrobat PDF
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A