Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Montana (BCBSMT). To access more downloadable forms, please log in to Blue Access for Producers.
To review and sign your request now electronically, select the sign now option below. Or you can download and save the form, to review and sign at a later date.
Forms for Individual Products (Under Age 65)
| Form Name | Digital Form | Download | ||
|---|---|---|---|---|
| 2023 Individual Paper Application Checklist | N/A | download form | ||
| 2023 Individual Health Plan Application/Change in Coverage (Off Exchange) Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) effective January 1, 2023, or to make changes to an existing BCBSMT policy. For individuals under age 65. |
N/A | download form | ||
| 2023 Individual Dental Plan Application/Change in Coverage Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2023, or to make changes to an existing BCBSMT policy. |
N/A | download form | ||
| Auto Bill Pay – Automatic Premium Payment Authorization Agreement | N/A | download form | ||
| Disabled Dependent Authorization Form (for Individual Plans) Members with an Individual 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). |
N/A | download form | ||
| UW15A – Potential Employer Contribution Form 1 | N/A | download form | ||
| UW15B – Potential Employer Contribution Form 2 | N/A | download form |
Enrollment Forms for Small Groups (2-50 Employees)
Form Name |
Digital Form |
Download |
2022 Small Group Enrollment Application/Change Form |
N/A |
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2023 Enrollment Package for New Small Groups |
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2023 Benefit Program Application (BPA) for New Small Groups |
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2023 Benefit Program Application (BPA) Amendment for Renewing Small Groups |
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2022 Benefit Program Application (BPA) for New Small Groups |
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2022 Benefit Program Application (BPA) Amendment for Renewing Small Groups |
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Affidavit of Domestic Partnership Instructions |
N/A |
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Benefit Wallet® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA integration with BenefitWallet. |
N/A |
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Composite Billing Guide and FAQs |
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Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank. |
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Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration. |
N/A |
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Disabled Dependent Authorization Form (for Group Plans) |
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Employer Group Information (EGI) Form – this form must be submitted with the BPA |
N/A |
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FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA integration with Flex. |
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HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet. |
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HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex. |
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HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity. |
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HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HSA Bank. |
N/A |
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Initial Premium EFT Payment Form |
N/A |
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Small Group Underwriting Reference Guide |
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Small Group Submission Checklist |
N/A |
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Summary of Benefits and Coverage (SBC) Notice for Small Groups |
N/A |
Renewal Forms for Small Groups (2-50 Employees)
| Form Name | Digital Form | Download |
|---|---|---|
| 2022 Small Group Enrollment Application/Change Form Use this form to apply for small group coverage effective 1/1/2022. |
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 Benefit Program Application (BPA) for New Small Groups |
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2023 Benefit Program Application (BPA) Amendment for Renewing Small Groups |
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| 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. |
sign now | download form  download form |
| 2022 Important Benefit Changes/Uniform Modification Notice Identifies some of the most important benefit plan changes for the upcoming 2022 coverage year |
N/A | download letter |
| Composite Billing Guide and FAQs For fully insured accounts (1-50 employees). |
N/A | download guide |
| 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 |
| Small Group Underwriting Reference Guide | N/A | download guide |
Forms for Large Groups (51+ Employees)
| 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 |
Benefit Wallet® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with BenefitWallet. |
N/A | download form |
Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank. |
N/A | download form |
Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration. |
N/A | download guide |
| 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 form |
| Employer Group Information (EGI) Form This form must be submitted with the BPA. |
sign now | download form |
FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex. |
N/A | download form |
HSA Employer Setup Form – Benefit Wallet® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet. |
N/A | download form |
HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex. |
N/A | download form |
HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity. |
N/A | download form |
HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank. |
N/A | download form |
| Initial Premium EFT Payment Form | sign now | download form |
| 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 |
| Merit Group Request for Proposal This form is completed by Sales Representatives and District Sales Managers with the group's insurance information. This will prompt the Underwriting work area to produce a quote. |
N/A | download form |
| Request for Proposal Use this form for new groups with 151+ eligible employees. |
N/A | download form |
Medicare Secondary Payer (MSP) Form and Information
| Form Name | Digital Form | Download |
|---|---|---|
| Medicare Secondary Payer (MSP) Employer Acknowledgement Form (EAF) 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 |
Forms for Medicare Products
Form Name |
Digital Form |
Download |
Application for Medicare Supplement Insurance Plan |
N/A |
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Application for Medicare Supplement Insurance Plan (Spanish Version) |
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Medicare Supplement Notice of Replacement |
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Medicare Supplement Outline of Coverage |
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Medicare Supplement Outline of Coverage (Spanish Version) |
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Medicare Supplement Outline of Coverage |
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Medicare Supplement Outline of Coverage (Spanish Version) |
N/A |
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 |
|---|---|---|
| Authorization for Release for Medical Records for Underwriting Purposes | N/A | download form |
| 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 |