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.

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 sign now download form
Group Enrollment Application/Change Form – Spanish N/A download form
2022 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after sign now N/A
2022 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after 1/1/2022 sign now download form Word Document
download form
2022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2022; use this form to amend the original BPA sign now download form Word Document
download form
2022 Important Benefit Changes/Uniform Modification Notice – identifies some of the most important benefit plan changes for the upcoming 2022 coverage year N/A download letter
2021 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after 1/1/2021 sign now download form
2021 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after 1/1/2021; use this form to amend the original BPA N/A download form
Employer Group Information (EGI) Form – this form must be submitted with the BPA N/A download form
Affidavit of Domestic Partnership sign now download form
Away From Home Care Guest Membership Application N/A download form
COBRA Agreement Form N/A download form
COBRA Endorsement B – Waiver of COBRA Administrator N/A download form
Common Ownership Form – Small Group 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

 

Miscellaneous Forms

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

 

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