Downloadable Forms for Medicare Products

Here are some commonly used forms for enrolling and maintaining your employer group coverage with Blue Cross and Blue Shield of New Mexico (BCBSNM).

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.

Form Name Digital Form Download
2022 Application for Medicare Supplement Insurance Coverage – Use this application when applying for a Medicare Supplement plan with an effective date on or after April 1, 2022. N/A download form
2021 Application for Medicare Supplement Insurance Coverage – Use this application when applying for a Medicare Supplement plan with an effective date on or after April 1, 2021. N/A download form
Medicare Supplement Notice of Replacement Form N/A download form
Medicare Supplement Other Coverage Questionnaire N/A download form
Medicare Supplement ezBlue Payment Option Authorization Form N/A download form

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download
Annual MSP Employer Acknowledgement Form (EAF) with Instructions on Completing the Form N/A download form
Information Regarding the MSP Statute N/A download PDF
MSP Fact Sheet N/A download PDF

 

Miscellaneous Forms

Form Name Digital Form Download
Medicare Coordination of Benefits Form N/A download form

 

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
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A