Forms and Documents

Here are some commonly used forms for conducting business with Blue Cross and Blue Shield of Montana (BCBSNM). 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

Form Name Digital Form Download
Authorization for Disclosure of Individual's Health Information or the Standard Authorization Form (SAF)
Use this form to authorize BCBSMT to disclose information to another person or entity.
N/A  download form Acrobat PDF
General Notice of Special Enrollment Rights N/A  download form Acrobat PDF
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.
N/A  download form Acrobat PDF
2015 Pediatric Dental Attestation Form - Employer
Small Group pediatric dental form for essential health benefits defined by ACA.
N/A  download form Acrobat PDF
2015 Pediatric Dental Attestation Form - Member Level
Member level pediatric dental form for essential health benefits defined by ACA.
N/A  download form Acrobat PDF
Potential Employer Contribution Form
Use this questionnaire form to determine potential employer contribution
N/A  download form Acrobat PDF
Scope of Appointment Form
Use this form before speaking with Medicare Part D or Medicare Advantage customers.
N/A  download form Acrobat PDF

Applications

Form Name Digital Form Download
2017 Enrollment Package 
Includes 2017 Benefit Program Application (BPA) for New Small Groups 2-50, Employer Group Information (EGI) Form, and Artifacts Documentation.
sign now External Link N/A 
2017 Benefit Program Application (BPA) for New Small Groups 2-50 
For new accounts effective on or after 1/1/2017.
sign now External Link download form Acrobat PDF
2017 Benefit Program Application (BPA) Amendment for Small Groups 2-50 
For renewing accounts with anniversary dates on or after 1/1/2017; use this form to amend the original BPA.
N/A  download form Acrobat PDF
2016 Benefit Program Application (BPA) for New Small Groups 2-50 
For new accounts effective on or after 1/1/2016.
sign now External Link download form Acrobat PDF
2016 Benefit Program Application (BPA) Amendment for Small Groups 2-50 
For renewing accounts with anniversary dates on or after 1/1/2016; use this form to amend the original BPA.
N/A  download form Acrobat PDF
2016 Benefit Program Application (BPA) for New Large Groups 101+ 
For new accounts effective on or after 1/1/2016
N/A  download form Acrobat PDF
2016 Managed Care Benefit Program Application (BPA) for New Large Groups 101+ 
For new managed care accounts effective on or after 1/1/2016
N/A  download form Acrobat PDF
2017 Health Application/Change in Coverage (Off Exchange)
Use this form to apply for a 2017 BCBSMT Individual Health Plan (Off Exchange) or to submit a change in coverage. For individuals under age 65.
N/A  download form Acrobat PDF
2016 Individual Plan New Application/Change in Coverage (Off Exchange)
Use this form to apply for a 2016 BCBSMT Individual Health Plan (Off Exchange) or to submit a change in coverage. For individuals under age 65.
N/A  download form Acrobat PDF
2016 Small Group Enrollment Application/Change Form 
Use this form to apply for small group coverage or to make changes to an existing BCBSMT policy.
sign now External Link download form Acrobat PDF
2016 Large Group Enrollment Application/Change Form 
Use this form to apply for large group coverage or to make changes to an existing BCBSMT policy.
N/A  download form Acrobat PDF
2017 Dental Application/Change in Coverage
Use this form to apply for a 2017 BlueCare Dental Individual Plan or to submit a change in coverage.
N/A  download form Acrobat PDF
2016 Dental Individual Plan New Application/Change in Coverage
Use this form to apply for a 2016 BlueCare Dental Individual Plan or to submit a change in coverage.
N/A  download form Acrobat PDF
Healthy Montana Kids Medicaid Plan Application
Use this form to apply for Healthy Montana Kids (HMK) Medicaid health insurance. Please submit the application to the address provided on application. The State of Montana's HMK Plan is a self-insured health plan and Blue Cross and Blue Shield of Montana acts only as the claims administrator.
N/A  download form Acrobat PDF
Application for Medicare Supplement Insurance Plan
Those who are eligible for Medicare can use this form to apply for BCBSMT insurance that will supplement their Medicare coverage.
N/A  download form Acrobat PDF
Composite Rate Billing Method Declaration Form
Use this form for new and existing fully insured accounts (1-50 employees). Includes Reference Guide to Composite Rating beginning January 2016.
sign now External Link download form Acrobat PDF
Composite Rate Billing Frequently Asked Questions
FAQs about composite billing available for new and existing fully insured accounts (1-50 employees), effective January 2016.
N/A  download form Acrobat PDF

Underwriting

Form Name Digital Form Download
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 Acrobat PDF
UW15A — Potential Employer Contribution Form 1 N/A  download form Acrobat PDF
UW15B — Potential Employer Contribution Form 2 N/A  download form Acrobat PDF
UW Release for Medical Records N/A  download form Acrobat PDF