Our most frequently requested forms are available in Adobe Acrobat PDF and Microsoft Word. Download the appropriate form, print the form, fill it out, and mail it to:
Medicaid UR Dept.
Blue Cross and Blue Shield of New Mexico
P.O. Box 27950
Albuquerque, NM 87125-7630
| Form Number | Form Name |
| MAD 046 | Individual Service Plan Waivers PDF 293KB MS Word 58KB Includes AIDS and AIDS-Related, Developmental Disabilities, Disabled and Elderly, Medically Fragile. |
| MAD 056 | EPSDT Personal Care Service Plan PDF 37KB |
| MAD 098 | Disabled & Elderly Individual Service Plan Waiver PDF 69KB MS Word 294KB |
| MAD 301 | Home Health Care (PDF 223KB |
| MAD 302 | Contact Lenses PDF 26KB MS Word 115KB |
| MAD 303 | Durable Medical Equipment (with medical justification forms, see list below): PDF 82KB Includes Occupational Therapy, Physical Therapy, Speech Therapy, and Surgery. Medical Justification Forms for Durable Medical Equipment: Wheelchair, Customized PDF 13KB MS Word 34KB Wheelchair, Lightweight PDF 13KB MS Word 34KB Wheelchair, Power PDF 14KB MS Word 38KB Wheelchair, Standard PDF 13KB MS Word 34KB Walker PDF 14KB MS Word 32KB Blood Pressure Monitor PDF 10KB MS Word 34KB Pulse Oximeter PDF 13KB MS Word 32KB Diapers PDF 14KB MS Word 33KB Bedside Commode PDF 11KB MS Word 32KB Raised Toilet Seat PDF 13KB MS Word 30KB Wall Mounted Grab Bars PDF 13KB MS Word 30KB Hospital Bed, Total Electric PDF 13KB MS Word 34KB Hospital Bed, Semi-Electric PDF 13KB MS Word 33KB Hospital Bed, Fixed PDF 13KB MS Word 31KB Oxygen Set Up and Oxygen Concentrators PDF 14KB MS Word 35KB Nebulizer Compressor PDF 14KB MS Word 31KB Pediatric Nebulizer PDF 13KB MS Word 31KB Home Apnea Monitor PDF 12KB MS Word 33KB Wound Vac Therapy PDF 14KB MS Word 37KB Nutritional Supplementation PDF 12KB MS Word 33KB |
| MAD 331 | Inpatient Rehab PDF 192KB |
| MAD 378 | Intermediate Care Facilities for Mentally Retarded (ICF/MR): PDF 378KB Includes Developmental Disabilities Waiver. |
| DOH 378 | Medically Fragile Waiver PDF 582KB |
| ISD 379 | Long-Term Care PDF 345KB Includes Aids and Aids Related Complex Waiver, Nursing Facility, Nursing Facility – PACE, Disabled and Elderly Waiver. |
| ISD 394 | Hearing Aid PDF 255KB |
You will need the Adobe Acrobat Reader to view the PDF forms above. This can be downloaded free of charge from Adobe's site.
