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 |
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2021 Individual Paper Application Checklist | N/A | download form |
2021 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, 2021, or to make changes to an existing BCBSMT policy. For individuals under age 65. |
N/A | download form |
2021 Dental Application/Change in Coverage Use this form to apply for a BlueCare Dental Individual Plan effective January 1, 2021, or to make changes to an existing BCBSMT policy. |
N/A | download form |
2022 Individual Paper Application Checklist | N/A | download form |
2022 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, 2022, or to make changes to an existing BCBSMT policy. For individuals under age 65. |
N/A | download form |
2022 Dental 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 |
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 |
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 |
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2021 Small Group Enrollment Application/Change Form Use this form to apply for small group coverage effective 1/1/2021. |
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 |
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 |
2021 Enrollment Package Includes Benefit Program Application (BPA), MSP Form, and Artifacts Documentation for new accounts effective 1/1/21 and after |
sign now | N/A |
2021 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2021. |
N/A | download form download form |
2021 Benefit Program Application (BPA) Amendment for Renewing Small Groups For renewing accounts with anniversary dates after January 1, 2021; use this form to amend the original BPA. |
N/A | 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 |
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 |
---|---|---|
2021 Small Group Enrollment Application/Change Form Use this form to apply for small group coverage effective 1/1/2021. |
N/A | download form |
2022 Benefit Program Application (BPA) for New Small Groups For new accounts effective January 1, 2022. |
sign now | 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 |
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 |
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2021 Large Group Enrollment Application/Change Form Use this form to apply for large group coverage effective January 1, 2021. |
N/A | download form |
2021 Benefit Program Application (BPA) for Large Groups For new accounts effective on or after January 1, 2021. |
N/A | download form download form |
2021 Benefit Program Application (BPA) for Managed Care Large Groups For new accounts effective on or after January 1, 2021. |
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 |
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 |
Forms for Medicare Products
Form Name | Digital Form | Download |
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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 |
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. |
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 2020 Medicare Supplement plan with an Effective Date on or after April 1, 2020. |
N/A | download form |
Medicare Supplement Outline of Coverage (Spanish Version) Use this outline of coverage when applying for a 2020 Medicare Supplement plan with an Effective Date on or after April 1, 2020. |
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 |
Scope of Sales Appointment Confirmation Form Use this form before speaking with Medicare Part D or Medicare Advantage customers. |
N/A | download form |
Medicare Secondary Payer (MSP) Form and Information
Form Name | Digital Form | Download |
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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 | download form |
Claim Forms
Form Name | Digital Form | Download |
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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 |
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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 |