Forms and Documents
Here you'll find the forms you need for program enrollment, account maintenance, supplies and more.
- 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.
- COBRA Election
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 Use this form to have premium payments automatically withdrawn from either a checking or savings account.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 laboratory services received at a Health 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 questionnaire 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.