Blue Access for Producers

Downloadable Forms for Small 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 .


SMALL GROUP FORMS (Groups of 2-50 — Off Exchange)
These downloadable forms are for use with off-exchange small group products.
Stock # / Date Proposal Forms New Mexico Form #
-- Request for Quote Proposal/Census Form (Groups 2-50)  N/A
Stock # / Date Enrollment Forms and Change Form New Mexico Form #
NM81797 DP Affidavit Affidavit of Domestic Partnership  N/A
N374 Away From Home Care Guest Membership Application  N/A
NM-SG-HP-NGF-BPA 08/15 2016 Benefit Program Application (BPA) for New Small Groups 2-50  — for new accounts effective on or after 1/1/2016 N/A
NM-SG-HP-NGF-BPA-A 09/15 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
NM-SG-HP-NGF-BPA-A 11/14 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
M469 9/07 Disabled Dependent Certification Form  N/A
81809.0814 2015 Group Enrollment Application/Change Form  — Use this form to apply for group coverage or make changes to an existing BCBSNM policy; for groups enrolling on or after 1/1/2015 N/A
475811.0115 2015 Group Enrollment Application/Change Form — Spanish  — Use this form to apply for group coverage or make changes to an existing BCBSNM policy; for groups enrolling/renewing on or after 1/1/2015 N/A
476908.1114 2015 Small Group Pediatric Dental Opt-Out 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
81720.0111 Student Medical Leave Certification 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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