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(additional group specific forms located at bottom of page)
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Use this form to have premium payments automatically withdrawn from either a checking or savings account.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.
Use these forms to complete a privacy related request. All forms,
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
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.
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 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 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
Perscription Drug Form
Use this form to request reimbursement when your drug benefit is processed directly through BCBSMT rather than through a third party Pharmacy Benefit Manger
Prime Mail New Prescription Order Form
Prime Mail Refill Prescription Order Form
Prime Reimbursement Claim Form
Ridgeway Mail Order Form
Group Specific Forms
Out-of-Network Exception Request Form
Billings Clinic Employees must complete an out-of-network exception request form prior to services performed.
Community Medical Center:
Out-of-Network Exception Request Form
Community Medical Center Employees must complete an out-of-network exception request form prior to services performed.
Stillwater Mining Company:
Affidavit of Common Law Marriage
This form is to be used and completed by members of Stillwater Mining Company only for Common law status.
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