Forms and Documents

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
2018 Individual Paper Application Checklist N/A  download form Acrobat PDF
2018 Individual Plan Health Application/Change in Coverage
(Off Exchange)

Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) effective January 1, 2018. For individuals under age 65.
N/A  download form Acrobat PDF
2018 Dental Application/Change in Coverage
Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2018.
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
UW15A — Potential Employer Contribution Form 1 N/A  download form Acrobat PDF
UW15B — Potential Employer Contribution Form 2 N/A  download form Acrobat PDF

Forms for Small Group Products (Groups of 2-50)

Form Name Digital Form Download
2018 Enrollment Package for New Small Groups 
Includes 2018 Benefit Program Application (BPA) for New Small Groups 2-50, Employer Group Information (EGI) Form, and Artifacts Documentation.
sign now External Link N/A
2018 Benefit Program Application (BPA) for New Small Groups 
For new accounts effective January 1, 2018.
sign now External Link download form Microsoft Word Document
download form Acrobat PDF
2018 Benefit Program Application (BPA) Amendment for Renewing Small Groups
For renewing accounts with anniversary dates after January 1, 2018; use this form to amend the original BPA.
N/A download form Microsoft Word Document
download form Acrobat PDF
Employer Group Information (EGI) Form for Small Groups
This form must be submitted with the BPA.
N/A download form Acrobat PDF
2018 Small Group Enrollment Application/Change Form
Use this form to apply for small group coverage effective January 1, 2018.
sign now External Link download form Acrobat PDF
Affidavit of Domestic Partnership N/A download form Acrobat PDF
Affidavit of Domestic Partnership Instructions N/A download info Acrobat PDF
Disabled Dependent Form
Use this form for a disabled dependent beyond the ACA mandated age limit of 26. Proof of disability is required.
N/A download info Acrobat PDF
2018 Composite Billing Guide and FAQs
For new fully insured accounts (1-50 employees) effective January 1, 2018.
N/A download guide Acrobat PDF
Small Group Submission Checklist N/A download form Acrobat PDF
Summary of Benefits and Coverage (SBC) Notice for Small Groups N/A  download notice Acrobat 

PDF

Forms for Large Group Products (Groups of 51+)

Form Name Digital Form Download
2018 Benefit Program Application (BPA) for Large Groups
For new accounts effective on or after January 1, 2018.
N/A  download form Microsoft Word Document
download form Acrobat PDF
2018 Benefit Program Application (BPA) for Managed Care Large Groups
For new accounts effective on or after January 1, 2018.
N/A  download form Microsoft Word Document
download form Acrobat PDF
2018 Large Group Enrollment Application/Change Form
Use this form to apply for large group coverage effective January 1, 2018.
N/A  download form Acrobat PDF
Affidavit of Domestic Partnership N/A download form Acrobat PDF
Affidavit of Domestic Partnership Instructions N/A download info Acrobat PDF
Disabled Dependent Form
Use this form for a disabled dependent beyond the ACA mandated age limit of 26. Proof of disability is required.
N/A download info Acrobat PDF
Request for Proposal
Use this form for new groups with 151+ eligible employees.
N/A download form Acrobat PDF
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

Forms for Medicare Products

Form Name Digital Form Download
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
Scope of Sales Appointment Confirmation Form
Use this form before speaking with Medicare Part D or Medicare Advantage customers.
N/A  download form Acrobat PDF

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download
Medicare Secondary Payer (MSP) Employer Acknowledgement Form
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.
sign now External Link download form Acrobat PDF

Claim Forms

Form Name Digital Form Download
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 Acrobat 

PDF
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 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 Department, Pharmacy, etc. Include a receipt or itemized statement.
N/A download form Acrobat PDF

Legal / HIPAA Forms

Form Name Digital Form Download
Authorization for Release for Medical Records for Underwriting Purposes N/A  download form Acrobat 

PDF
Notice of Special Enrollment Rights in Your Group Health Plan N/A download notice Acrobat PDF
Standard Authorization Form and other HIPAA Privacy Forms N/A access forms Acrobat PDF