Forms and Documents
Here you'll find all the forms you need for program enrollment, account maintenance, supplies and more.
- 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.
- Employer Group Listing
Must accompany employee health statements and Small Group Worksheet to receive a quote outside the BlueKey Portal.
- General Notice of Special Enrollment Rights
- 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.
- 2015 Pediatric Dental Attestation Form - Employer
Small Group pediatric dental form for essential health benefits defined by ACA.
- 2015 Pediatric Dental Attestation Form - Member Level
Member level pediatric dental form for essential health benefits defined by ACA.
- Potential Employer Contribution Form
Use this questionnaire form to determine potential employer contribution
- Scope of Appointment Form
Use this form before speaking with Medicare Part D or Medicare Advantage customers.
- 2015 Large Group Enrollment Application
- 2015 Small Group Enrollment Application
- 2015 Application for Individual Plans Off Exchange
Use this form to apply for individual coverage, add dependents, or change in coverage off the Exchange.
- 2015 Application for Individual Dental
- 2014 Application and/or Waiver of Coverage for Group Benefit Plans
- 2014 Application and/or Waiver of Coverage for Group Benefit Plans Notice of Preexisting Condition Exclusion and Special Enrollment
- 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 Senior Care - Simply Blue
Use this form to apply for insurance that will supplement your Medicare coverage.
- Application for Short-Term Blue
Use this link to apply for short-term health care coverage of Preexisting Condition Exclusion and Special Enrollment.
- 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.
- Small Group Worksheet
Sales Represesentatives and District Sales Managers complete the Small Group Worksheet, which must be attached to the customer's employee health statements. The Employer Group Listing is provided to the Underwriting work area to produce a quote.
- UW15A — Potential Employer Contribution Form 1
- UW15B — Potential Employer Contribution Form 2
- UW Release for Medical Records