Blue Cross Blue Shield Name Change Authorization Forms

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 thesign 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
2022 Individual Paper Application Checklist	N/A	download form
2022 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, 2022, or to make changes to an existing BCBSMT policy. For individuals under age 65.	N/A	download form
2022 Individual Dental Plan Application/Change in Coverage Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2022, 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 Use this form to apply for small group coverage effective 1/1/2022.	N/A	download form
2022 Enrollment Package for New Small Groups Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after.	sign now	N/A
2022 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2022.	sign now	download form download form
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
Employer Group Information (EGI) Form for Small Groups This form must be submitted with the BPA.	N/A	download form
Affidavit of Domestic Partnership	N/A	download form
Affidavit of Domestic Partnership Instructions	N/A	download info
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
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
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	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
FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA 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 and/or FSA 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 and/or FSA integration with HSA Bank.	N/A	download form
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.	N/A	download form
Composite Billing Guide and FAQs For fully insured accounts (1-50 employees).	N/A	download guide
Small Group Underwriting Reference Guide	N/A	download guide
Small Group Submission Checklist	N/A	download form
Summary of Benefits and Coverage (SBC) Notice for Small Groups	N/A	download notice
Initial Premium EFT Payment Form	N/A	download form

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
2022 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2022.	sign now	download form download form
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
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
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
Employer Group Information (EGI) Form This form must be submitted with the BPA.	sign now	download form
Affidavit of Domestic Partnership	N/A	download form
Affidavit of Domestic Partnership Instructions	N/A	download info
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
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
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
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
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/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
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
Request for Proposal Use this form for new groups with 151+ eligible employees.	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
Initial Premium EFT Payment Form	sign now	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 Those who are eligible for Medicare can use this form to apply for BCBSMT insurance that will supplement their Medicare coverage with an Effective Date on or after May 1, 2022.	N/A	download form
Application for Medicare Supplement Insurance Plan (Spanish Version) Those who are eligible for Medicare can use this form to apply for BCBSMT insurance that will supplement their Medicare coverage with an Effective Date on or after May 1, 2022.	N/A	download form
Medicare Supplement Notice of Replacement	N/A	download form
Medicare Supplement Outline of Coverage Use this outline of coverage when applying for a 2021 Medicare Supplement plan with an Effective Date on or after April 1, 2021.	N/A	download form
Medicare Supplement Outline of Coverage (Spanish Version) Use this outline of coverage when applying for a 2021 Medicare Supplement plan with an Effective Date on or after April 1, 2021.	N/A	download form
Medicare Supplement Outline of Coverage Use this outline of coverage when applying for a 2022 Medicare Supplement plan with an Effective Date on or after May 1, 2022.	N/A	download form
Medicare Supplement Outline of Coverage (Spanish Version) Use this outline of coverage when applying for a 2022 Medicare Supplement plan with an Effective Date on or after May 1, 2022.	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

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

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Source: https://www.bcbsmt.com/producer/forms/downloadable-forms/downloadable-forms

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