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Affidavit of Domestic Partnership
Affidavit of Domestic Partnership Instructions
Change of Status Form (Member)
Use this form to make changes to your coverage. The following changes can be submitted: Name changes, address changes, billing address changes (only for non-group members), PCP (Personal Care Physician) changes, cancellations of self or dependents, and requests for changing billing methods (only for non-group members). Note: For group coverage, you may be required to notify your employer's group leader.
Use this form to apply for COBRA coverage, if available, when group coverage has been terminated.
COBRA Qualifying Event Form
BCBSMT sends this out to you when you have experienced a qualifying event. This is only used when BCBSMT is the administrator of COBRA for a group.
Electronic Funds Transfer (EFT) Authorization
Only for groups already converted to Blue Access for Employers. Use this form to have premium payments automatically withdrawn from either a checking or savings account.
Employer Group Information (EGI) Form
For Small Employer Groups (2-50) that have reached their 2014 Renewal Dates - Use the EGI form to submit employee counts for COBRA, Medicare Secondary Payor Status and Medical Loss Ratio.
Employer Group Listing
Must accompany employee health statements and Small Group Worksheet to receive a quote outside the BlueKey Portal.
Employer List Bill Agreement Form
Employers can establish a List Bill to indicate all eligible employees' individual health insurance policy premiums they'll collect and then pay to BCBSMT.
Health Fair, Lab and Immunization Submission Form
Use this form to submit preventative immunization or labratory services received at a Heath Fair, a City/County Health Dept, Pharmacy, etc. along with a receipt or itemized statement.
2015 Pediatric Dental Attestation Form - Employer
Small Group pediatric dental form for essential health benefits defined by ACA.
2015 Pediatric Dental Attestation Form - Member Level
Member level pediatric dental form for essential health benefits defined by ACA.
Potential Employer Contribution Form
Use this questionaire form to determine potential employer contribution
Work Hours Endorsement Form
Employers use this form to specify the employer's work hour requirement for eligibility for employees to be eligible for coverage.
Large Group Enrollment Application
Small Group Enrollment Application
Small Group Application
Renewing Small Group Application
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association. © Copyright 2014 Health Care Service Corporation. All Rights Reserved.