Member Forms

  • Affidavit of Domestic Partnership PDF Document
  • Appeal Review Form (Member) PDF Document
    Use this form to complete an appeal request
  • Claim Form – Medical (Domestic) PDF Document
    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.
  • Claim Form – Medical (International) PDF Document
    Use this BlueCard Worldwide 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.
  • Change of Status Form (Member) PDF Document
    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 PDF Document
    Use this form to apply for COBRA coverage, if available, when group coverage has been terminated.
  • COBRA Qualifying Event Form PDF Document
    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 PDF Document
    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 PDF Document
    Member level pediatric dental form for essential health benefits defined by ACA.
  • Disabled Dependent Form PDF Document
    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) for O65 Medicare Supplement Coverage PDF Document
    Use this form to have premium payments automatically withdrawn from either a checking or savings account.
  • Electronic Funds Transfer (EFT) for U65 Coverage PDF Document
    Use this form to have premium payments automatically withdrawn from either a checking or savings account.
  • Health Fair, Lab and Immunization Submission Form PDF Document
    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 PDF Document
    Use this form to a request an appeal of declined coverage.
  • Small Estate Affidavit PDF Document
    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 PDF Document
    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

Group Specific Forms