Downloadable Forms for Mid-Market Group Products

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 (BAP).

The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe^® Reader^®. Other Adobe accessibility tools and information can be downloaded at access.adobe.com .

MID-MARKET (NRSG) GROUP FORMS (Groups of 51-100) These downloadable forms are for use with non-regulated small group products.
Stock # / Date	Enrollment Forms and Change Forms	New Mexico Form #
NM-LG-HP-(Standard)-BPA	2016 Benefit Program Application (BPA) for Groups 51-100  – for new accounts effective on or after 1/1/2016	N/A
477868.1216	2017 Group Enrollment Application/Change Form  – use this form to apply for group coverage or to make changes to an existing BCBSNM policy	N/A
NM81797 DP Affidavit	Affidavit of Domestic Partnership	N/A
H374	Away From Home Care Guest Membership Application	N/A
M469 9/07	Disabled Dependent Certification Form	N/A
NM81797 Term Statement	Statement of Termination of Domestic Partnership	N/A
Stock # / Date	Miscellaneous Forms	New Mexico Form #
CS01 10/07	Coordination of Benefits Form	N/A
--	Medicare Coordination of Benefits Form	N/A
Stock # / Date	Medicare Secondary Payer (MSP) Form and Information	New Mexico Form #
21127.0913	Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form	N/A
21093.0609	Information Regarding the Medicare as Secondary Payer Statute	N/A
82284.0612	MSP Fact Sheet	N/A
Stock # / Date	Legal / HIPAA Forms	New Mexico Form #
--	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
11.01.16	Standard Authorization Form and other HIPAA Privacy Forms	N/A