Member Forms

• Select the form you wish to submit
• Print and complete the form as instructed
• When printing, please select "Print as Image" on the print screen.

You may fax or mail the completed forms to:

Blue Cross and Blue Shield of Montana
PO Box 4309
Helena, MT 59604
FAX: 1.406.791.4119

Accident Form
This form is required to be completed by the member to ensure proper payment of the member's claims based on their Accident provision of their coverage.

Affidavit of Domestic Partnership

Application for Individual Plans
Complete this form to apply for individual coverage, add dependents to your exisiting coverage, change benefit plans, or transfer from another coverage.

Application for Montana Youthcare
Montana Youthcare is for children from age 3 months through 18 years.  Applicants/Members must be Montana residents.

Application for Senior Care
Use this form to apply for insurance that will supplement your Medicare coverage.

Application for Short-Term Blue
Use this form to apply for short-term health care coverage.  The duration of coverage may be from 30 to 183 days. You must be a Montana resident to apply.

Application and/or Waiver of Coverage for Group Benefit Plans
Use this form to apply for group coverage, add dependents to your group coverage, waive coverage, or transfer from one policy to another.  Notify your group leader when adding dependents. Your group leader must sign this form when applying for group coverage.

Authorization for Disclosure of an Individual's Health Information
BCBSMT protects the privacy of your health information. If you would like BCBSMT to provide your protected health information to someone other than yourself, you must submit this form.

COB - Coordination of Benefits
Complete this form when more than one insurance company may be paying claims.  Upon receipt of this form, BCBSMT will continue to process any claims that are pending.

Change of Status
Use this form to to make changes to your coverage.  The following changes can be submitted: Name, Address, and Primary Care Provider as well as cancellation of Self or Dependents, etc.

Electronic Funds Transfer (EFT) Authorization
Use this form to have premium payments automatically withdrawn from either a checking or savings account.  EFT is not currently available for COBRA members.

Express Scripts Member Reimbursement Form
You are encouraged to have your claims processed electronically at your pharmacy to ensure the best price.  However, if the pharmacy is unable to process electronically or you forgot your ID card, you can submit your claim to ESI using this form.

Out-of-State Travel Preauthorization for the State of Montana Employee Benefit Plan
The State of Montana benefit plan offers a travel benefit for out-of-state services that cannot be rendered in Montana.

Prescription Drug Claim
Use this form to request reimbursement when your drug benefit is processed directly through BCBSMT rather than through a third party Pharmacy Benefit Manager.

Student Certification Form **
This form is required for a parent to retain a dependent on their coverage after the dependent reaches the maximum dependent age as stated in their contract but has not reached the maximum student age.  This form may or may not pertain to your particular group.  Contact your group leader for details.