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Member Forms:

All Forms (additional group specific forms located at bottom of page)

  • Accident Form
    Members use this form to ensure proper payment of the member’s claims based on the accident provision of the coverage.
  • Affidavit of Domestic Partnership
  • Affidavit of Domestic Partnership Instructions
  • Appeal Review Form (Member)
    Use this form to complete an appeal request   
  • BlueCard Worldwide International Claim Form
    For Members traveling out of the country for medical services, this form must be completed after having services in a hospital, treated by a professional medical provider, or medical vision services.
  • 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.  
  • COBRA Election Form
    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.
  • Coordination of Benefits – COB
    Use 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.  You may also login to Member Online Services and submit the information by selecting the Coordination of Benefits option located on the left side menu.  
  • Dental Claim Form
    Dental providers use this form to request compensation for dental services.  
  • Dental Pediatric Member Level Form
    Complete this form to attest out of pediatric dental essential health benefits defined by ACA.
  • Electronic Funds Transfer (EFT) Authorization
    Use this form to have premium payments automatically withdrawn from either a checking or savings account. EFT is now available for COBRA members.
  • 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.
  • Privacy Forms
    Use these forms to complete a privacy related request. All forms, click here
    • Standard of Authorization Form (Authorization for Disclosure of Individual's Health Information)
    • Request to Access PHI
    • Request to Amend PHI
    • Request for Accounting of PHI Disclosures
    • Respond to Denied Amendment
    • Confidential Communication Request
    • Restriction Request
    • HIPAA Complaint
  • Potential Employer Contribution Form
    Use this questionaire form to determine potential employer contribution  
  • Request for Appeal of Coverage Declination
    Use this form to a request an appeal of declined coverage.
  • Small Estate Affidavit
    Use this form when an estate is not being probated and the value of the estate held only in the deceased's name is less than $50,000.  
  • Transitional Care Benefit Request Form 
    Please complete this form if you are currently receiving medical care from physician(s) that are not listed in your provider directory and would like assistance in coordinating your medical care with the new medical plan. It may be necessary to request medical information from your current physician(s).

 

Applications

Pharmacy

Pharmacy Drug:

Group Specific Forms

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