Downloadable Forms for Mid-Market Groups (NRSG)
(51-100 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 |
|---|---|---|
| 2018 Group Enrollment Application/Change Form – use this form to apply for group coverage effective 1/1/2018 | sign now  |
download form  |
| 2018 Group Enrollment Application/Change Form – Spanish | N/A | download form |
| 2017 Group Enrollment Application/Change Form – use this form to apply for group coverage (through 12/31/2017) or make changes to an existing BCBSNM policy | sign now |
download form |
| 2017 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 |
| Disabled Dependent Certification Form | sign now |
download form |
| Statement of Termination of Domestic Partnership | N/A | download form |
| Mid-Market Initial Premium EFT Payment Form | N/A | download form |
Medicare Secondary Payer (MSP) Form and Information
| Form Name | Digital Form | Download |
|---|---|---|
| Annual MSP Employer Acknowledgement Form with Instructions on Completing the Form | N/A | download form |
| Information Regarding the Medicare as Secondary Payer Statute | N/A | download form |
| MSP Fact Sheet | 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 |
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 |
