Forms

These forms are available as PDF files. Just click on a form, print the form, and fill it out.

Primary Care Provider Selection Form – Blue Cross Community Centennial Members must select a PCP. Fill in your PCP's information and mail the completed form to BCBSNM.

Infant Car Seat and Crib Program – Use this form to write down your doctor visits. Have your doctor sign it with each visit. Follow the instructions on the form before sending it to BCBSNM.

Baby Wrap Carrier – Members can get a wrap carrier from BCBSNM if you enroll in the Special Beginnings® program and complete a postpartum visit (21-56 days after your baby is born). Use this form to write down your doctor visit. Your doctor must sign and date the form before you send it to BCBSNM.

Eyeglasses Reimbursement – This form is only for ABP Medicaid Expansion Population members who are 21 years and older and have diabetes and/or high blood pressure. Use the form to keep track of eye doctor visits and test results. Your doctor must sign and date the form before you send it to BCBSNM.

Patient Medication List Form – Keep a record of your medications on hand to share with your doctor.

Medicaid Prescription Drug Claim Form – Complete this form to submit a claim for a prescription. You must submit the original pharmacy receipt with the form.

Medicaid Prescription Mail-Order Form – Use this form to mail order new or refill prescription maintenance medicines. Mail the completed form to the address on the form. You must include the original prescription signed by your doctor.

Medicaid Rx Mail-Order Flier – Learn how to order the medicines that you take long-term or every day. You can have them delivered to your home.

Transportation – Mileage Reimbursement Form – Also see Guidelines for Mileage Reimbursement

Transportation – Meals and Lodging Expense Report Form – Also see Guidelines for Meals and Lodging Reimbursement

Provider Form for Transportation Attendant – Use this form if you want to bring someone with you on a trip to/from an appointment. Your doctor will need to confirm it is medically necessary for an escort to go with you. This form must be sent in before you arrange to bring someone with you. Your doctor can fax the completed form to 1-866-402-0522.

Member Appeal Request Form – You or your appointed representative may use this form to file an appeal. Please see the instructions on the form to learn how to file an appeal.

Provider Appeal Request Form – You can have your provider submit an appeal for you. Use this form and please follow the instructions. Your provider will need to include certain information to support the request. Also, you must sign the form. Once completed, send it to the address shown on the form.

Power of Attorney Form – Have someone you trust to make health care decisions if you are unable to do so. Follow instructions on the form.

Standard Authorization Form and other Privacy Forms