Downloadable Forms for Mid-Market Groups (NRSG) (51-150 Employees)

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of New Mexico (BCBSNM). To access more downloadable forms, please log in to Blue Access for Producers.

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.

These downloadable forms are for use with non-regulated small group products.

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

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

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

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

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/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

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
COBRA Agreement Form N/A download form
COBRA Endorsement B – Waiver of COBRA Administrator 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
Mid-Market Initial Premium EFT Payment 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 N/A download form
Information Regarding the MSP Statute N/A download flier
MSP Fact Sheet N/A download fact sheet

 

Miscellaneous Forms

Form Name Digital Form Download
Coordination of Benefits 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
Standard Authorization Form and other HIPAA Privacy Forms N/A N/A