Download Forms for Individual & Family Markets 

Here are some commonly used forms and documents producers need for conducting business with Blue Cross and Blue Shield of Montana. To access more downloadable forms, please log in to your Blue Access for Producers account.

Using PDFs
Most of the forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

Forms for Individual Products (Under 65)

Form Name Digital Form Download
2024 Individual Paper Application Checklist N/A download form
2024 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, 2024, or to make changes to an existing BCBSMT policy. For individuals under age 65.
N/A download form
2024 Individual Dental Plan Application/Change in Coverage
Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2024, or to make changes to an existing BCBSMT policy.
N/A download form
2024 Individual Paper Application Overflow Page N/A download form
Auto Bill Pay – Automatic Premium Payment Authorization Agreement
Reduce the chance of your policy being cancelled for non-payment. Members can use this form to set up electronic payments for their plan. This will allow BCBSMT to deduct the monthly premium from their checking or savings account.
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

 

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

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Last Updated: March 01, 2024