- Affidavit of Domestic Partnership
- 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.
- Breast Pump Benefit form
Blue Cross and Blue Shield of Montana (BCBSMT) may reimburse a new mother for the purchase of one breast pump per pregnancy. To submit a reimbursement request, follow these simple steps:
- Contact a BCBSMT Customer Service Representative at 800-447-7828 to verify your particular plan offers this benefit.
- Purchase the breast pump of your choice (be sure to retain the UPC code of the product). NOTE: Hospital-grade pumps may be rented, as needed. Otherwise, any non-hospital grade pump is eligible for reimbursement.
- Click on the button below to obtain the Breast Pump Benefit Form.
- Complete all fields of the form and attach the receipt. (Make a copy for your records).
- Mail the completed form and receipt to the address listed. You will receive a check in the mail for the cost of the breast pump.
- 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.
- 2015 Pediatric Dental Attestation Form - Member Level
Member level pediatric dental form for essential health benefits defined by ACA.
- Disabled Dependent Form
Use this form if you have a disabled dependent beyond the ACA mandated age limit of 26. Proof of disability is required.
- 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 Medicare Supplement members.
- 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 Dept, Pharmacy, etc. along with a receipt or itemized statement.
- Privacy Forms
Use these forms to complete a privacy related request. View all the forms mentioned below.
- 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
- 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).
- 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 2015 Individual Plans Off Exchange
Use this form to apply for individual coverage, add dependents, or change in coverage off the Exchange.
- Application for Senior Care - Simply Blue
Use this form to apply for insurance that will supplement your Medicare coverage.
- Application and/or Waiver of Coverage for Group Benefit Plans Notice of Preexisting Condition Exclusion and Special Enrollment
- Prime Mail New Prescription Order Form
- Prime Mail Refill Prescription Order Form
- Prime Reimbursement Claim Form
- Ridgeway Mail Order Form
Group Specific Forms
- Billings Clinic: 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.
- MUS Faculty/Staff Vision Claim Form
- MUST Immunization Submission Form
- Ranch and Home Supply Massage Therapy Claim Form