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Agent of Record
Use this form to authorize a change in Agent
Authorization for Disclosure of Individual's Health Information or the Standard Authorization Form (SAF)
Use this form to authorize BCBSMT to disclose information to another person or entity.
Dental Pediatric Member Level Form
Complete this form to attest out of pediatric dental essential health benefits defined by ACA.
Dental Pediatric Small Group
Small Group pediatric dental form for essential health benefits defined by ACA
Employer Group Listing
Must accompany employee health statements and Small Group Worksheet to receive a quote outside the BlueKey Portal.
Immunization Claim Form
Use this form to submit preventative immunization service received at a Heath Fair, a City/County Health Dept, Pharmacy, etc. along with a receipt or itemized statement.
Lab Services Claim Form
Use this form to submit laboratory services received at a Heath Fair, a City/County Health Dept, etc. along with a receipt or itemized statement.
Potential Employer Contribution Form
Use this questionaire form to determine potential employer contribution
Scope of Appointment Form
Use this form before speaking with Medicare Part D or Medicare Advantage customers.
Application for Healthy Montana Kids (HMK)
Use this form to apply for Healthy Montana Kids (HMK) insurance. Please submit the application to the address provided on application. The State of Montana’s Healthy Montana Kids Plan is a self-insured health plan and Blue Cross and Blue Shield of Montana acts only as the claims administrator.
Application for Individual Plans for 2013
Use this form to apply for individual coverage, add dependents to your existing coverage, change benefit plans, or transfer from other coverage. (Blue Evolution, HDHP Montana Ind. Plan, HDHP Premier, Value Blue)
Application for 2014 Individual Plans off Exchange
Use this form to apply for individual coverage, add dependents, or change in coverage off the Exchange.
Application for Senior Care - Simply Blue
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 30 - 183 days. You must be a Montana resident to apply.
Application and/or Waiver of Coverage for Group Benefit Plans
Application and/or Waiver of Coverage for Group Benefit Plans Notice
of Preexisting Condition Exclusion and Special Enrollment
Group Application Short Form
Use this form for either quoting new merit groups with 30+ enrolled employees or the enrollment of new merit members.
Merit Group Request for Proposal
This form is completed by Sales Representatives and District Sales Managers with the group's insurance information. This will prompt the Underwriting work area to produce a quote.
Small Group Worksheet
Sales Represesentatives and District Sales Managers complete the Small Group Worksheet, which must be attached to the customer's employee health statements. The Employer Group Listing is provided to the Underwriting work area to produce a quote.
- Potential Employer Contribution Form 1
- Potential Employer Contribution Form 2
UW Release for Medical Records
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association. © Copyright 2013 Health Care Service Corporation. All Rights Reserved