Forms and Documents
Here are some commonly used forms you need for Blue Cross and Blue Shield of Montana (BCBSMT) program enrollment, account maintenance, supplies and more.
To review and sign your request now, select the sign now option. Or you can download and save the form, to review and sign later.
Forms for Small Group Products (Groups of 2-50)
| Form Name | Digital Form | Download |
|---|---|---|
| 2022 Small Group Enrollment Application/Change Form Use this form to apply for small group coverage effective January 1, 2022. |
N/A | download form |
| 2023 Important Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the upcoming 2023 coverage year. |
N/A | download letter |
| 2023 Enrollment Package Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after. |
sign now | N/A |
| 2023 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2023. |
sign now | download form  download form |
| 2023 Benefit Program Application (BPA) Amendment for Renewing Small Groups For renewing accounts with anniversary dates after January 1, 2023; use this form to amend the original BPA. |
sign now | download form download form |
Employer Group Information (EGI) Form – this form must be submitted with the BPA |
N/A |
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| 2022 Enrollment Package Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after. |
sign now | N/A |
| 2022 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2022. |
N/A | download form download form |
| 2022 Benefit Program Application (BPA) Amendment for Renewing Small Groups For renewing accounts with anniversary dates after January 1, 2022; use this form to amend the original BPA. |
N/A | download form download form |
| Disabled Dependent Authorization Form (for Group Plans) Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSMT (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application). |
N/A | download info |
| Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. | N/A | download form |
| Summary of Benefits and Coverage (SBC) Monitoring Performance | N/A | download form |
| Summary of Benefits and Coverage (SBC) Notice for Small Groups | N/A | download notice |
Forms for Large Group Products (Groups of 51+)
| Form Name | Digital Form | Download |
|---|---|---|
| 2022 Large Group Enrollment Application/Change Form Use this form to apply for large group coverage effective January 1, 2022. |
N/A | download form |
| 2023 Benefit Program Application (BPA) for Large Groups For new accounts effective on or after January 1, 2023. |
N/A | download form download form |
| 2023 Benefit Program Application (BPA) for Managed Care Large Groups For new accounts effective on or after January 1, 2023. |
N/A | download form download form |
| 2023 Important Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the 2023 - 2024 coverage year. |
N/A | download form download form |
| 2022 Benefit Program Application (BPA) for Large Groups For new accounts effective on or after January 1, 2022. |
N/A | download form download form |
| 2022 Benefit Program Application (BPA) for Managed Care Large Groups For new accounts effective on or after January 1, 2022. |
N/A | download form download form |
| Affidavit of Domestic Partnership | N/A | download form |
| Affidavit of Domestic Partnership Instructions | N/A | download info |
| Disabled Dependent Authorization Form (for Group Plans) Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSMT (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application). |
N/A | download info |
| Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. | N/A | download form |
| Summary of Benefits and Coverage (SBC) Monitoring Performance | N/A | download form |
Medicare Secondary Payer (MSP) Form and Information
| Form Name | Digital Form | Download |
|---|---|---|
| Medicare Secondary Payer (MSP) Employer Acknowledgement Form In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form. |
N/A | download form |
Claim Forms
| Form Name | Digital Form | Download |
|---|---|---|
| Claim Form – Dental Use this form to file dental claims for reimbursement that are not filed by your dental provider. |
N/A | download form |
| Claim Form – Medical (Domestic) Use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. |
N/A | download form |
| Claim Form – Medical (International) Use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base. |
N/A | download form |
| Health Fair, Lab and Immunization Submission Form Use this form to submit preventative immunization or laboratory services received at a Heath Fair, a City/County Health Department, Pharmacy, etc. Include a receipt or itemized statement. |
N/A | download form |
Miscellaneous Forms
| Form Name | Digital Form | Download |
|---|---|---|
| Producer of Record Transfer Form and Instructions | N/A | download form |
Legal / HIPAA Forms
| Form Name | Digital Form | Download |
|---|---|---|
| Notice of Special Enrollment Rights in Your Group Health Plan | N/A | download notice |
| Standard Authorization Form and other HIPAA Privacy Forms | N/A | access forms |
