Downloadable Forms for Small Groups (2-50 Employees)

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.

Enrollment Forms

Form Name	Digital Form	Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or make changes to an existing BCBSNM policy	N/A	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
2024 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/24 and after	sign now	N/A
2024 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after 1/1/2024	sign now	download form  download form
2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2024; use this form to amend the original BPA	sign now	download form  download form
2023 Important Benefit Changes/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2023 coverage year	N/A	download notice
2023 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after	sign now	N/A
2023 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after 1/1/2023	sign now	download form  download form
2023 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2023; use this form to amend the original BPA	sign now	download form  download form
Employer Group Information (EGI) Form – this form must be submitted with the BPA	sign now	download form
Common Ownership Form – Small Group	N/A	download form
Dependent Student Medical Leave Certification Form	N/A	download form
Disabled Dependent Authorization Form (for Group Plans) – Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSNM (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).	N/A	download form
Statement of Termination of Domestic Partnership	N/A	download form

Renewal Forms

Form Name	Digital Form	Download
2024 Important Benefit Changes/Uniform Modification Notice – Identifies some of the most important benefit plan changes for the 2024 coverage year.	N/A	download form
Group Enrollment Application/Change Form – use this form to apply for group coverage or make changes to an existing BCBSNM policy	sign now	download form
Group Enrollment Application/Change Form – Spanish	N/A	download form
2024 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after 1/1/2024	sign now	download form  download form
2024 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2024; use this form to amend the original BPA	sign now	download form  download form
Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled.	sign now	download form
Average Employee Count (AEC) Form	sign now	download form

Miscellaneous Forms

Medicare Secondary Payer (MSP) Form and Information

Legal / HIPAA Forms