Downloadable Forms for Mid-Market (NRSG) Groups (51-150 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
2023 Benefit Program Application (BPA) for Mid-Market Groups 51-150 – for new and renewing Mid-Market Group accounts effective on or after 1/1/2023 N/A download form
Employer Group Information (EGI) Form sign now download form
Affidavit of Domestic Partnership sign now download form
Away From Home Care Guest Membership Application 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 and Information

Form Name Digital Form Download
7/1/2024 Important Benefit Changes/Uniform Modification Notice - Identifies some of the most important benefit plan changes for the 2024 coverage year. N/A download notice  
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  


Medicare Secondary Payer (MSP) Form and Information

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


Miscellaneous Forms

Form Name Digital Form Download
Coordination of Benefits Form N/A download form
Producer of Record Transfer Form N/A download form
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
Power of Attorney for Health Care – Spanish N/A download form
Standard Authorization Form and other HIPAA Privacy Forms N/A access forms