Downloadable Forms for Large Groups (151+ Employees)

Enrollment Forms and Change Forms

Form Name Digital Form Download
Group Enrollment Application/Change Form – use this form to apply for group coverage or to make changes to an existing BCBSNM policy sign now download form
Group Enrollment Application/Change Form – Spanish N/A download form
Affidavit of Domestic Partnership sign now download form
Away From Home Care Guest Membership Application N/A download form

Benefit Wallet® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with BenefitWallet.

 N/A download form

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSNM to BenefitWallet, HealthEquity or HSA Bank.

 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

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

 N/A download form

HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet.

 N/A download form

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

 N/A download form

HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

 N/A download form

HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.

 N/A download form
Statement of Termination of Domestic Partnership N/A download form

 

Renewal Forms and Information

Form Name Digital Form Download
2023–2024 Important Benefit Changes/Uniform Modification Notice - Identifies some of the most important benefit plan changes for the 2023–2024 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