Member Forms

• Affidavit of Domestic Partnership 
• Appeal Review Form (Member) 
  Use this form to complete an appeal request
• Authorized Representative for Internal Appeal and External Review Form 
  Use this form to authorize providers or other authorized representatives to submit appeals on your behalf.
• 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.
• 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.
• Change of Status Form (Member) 
  Use this form to make changes to your coverage. The following changes can be submitted: Name changes, address changes, billing address changes (only for non-group members), PCP (Personal Care Physician) changes, cancellations of self or dependents, and requests for changing billing methods (only for non-group members). Note: For group coverage, you may be required to notify your employer's group leader.
• COBRA Election Form 
  Use this form to apply for COBRA coverage, if available, when group coverage has been terminated.
• COBRA Qualifying Event Form 
  BCBSMT sends this out to you when you have experienced a qualifying event. This is only used when BCBSMT is the administrator of COBRA for a group.
• Coordination of Benefits – COB 
  Use this form when more than one insurance company may be paying claims. Upon receipt of this form, BCBSMT will continue to process any claims that are pending.  You may also login to Member Online Services and submit the information by selecting the Coordination of Benefits option located on the left side menu.
• Disabled Dependent Authorization Form (for Individual Plans) 
  Members with an Individual health plan: Use this form to request continuation of coverage on your 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).
• Disabled Dependent Authorization Form (for Group Plans) 
  Members with an employer-sponsored health plan: Use this form to request continuation of coverage on your 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).
• Electronic Funds Transfer (EFT) for O65 Medicare Supplement Coverage 
  Use this form to have premium payments automatically withdrawn from either a checking or savings account.
• Electronic Funds Transfer (EFT) for U65 Coverage 
  Use this form to have premium payments automatically withdrawn from either a checking or savings account.
• Health Fair, Lab and Immunization Submission Form 
  Use this form to submit preventative immunization or laboratory services received at a Health Fair or Pharmacy along with a receipt or itemized statement.
• Privacy Forms
  Use these forms to complete a privacy related request. View all the forms mentioned below.
  • Standard of Authorization Form (Authorization for Disclosure of Individual's Health Information)
  • Request to Access PHI
  • Request to Amend PHI
  • Request for Accounting of PHI Disclosures
  • Respond to Denied Amendment
  • Confidential Communication Request
  • Restriction Request
  • HIPAA Privacy and Security Complaint
• Request for Appeal of Coverage Declination 
  Use this form to a request an appeal of declined coverage.

Applications

• 2021 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, 2021, or to submit a change in coverage. For individuals under age 65.
• 2021 Individual Dental Plan Application/Change in Coverage 
  Use this form to apply for a BCBSMT Individual Dental Plan effective January 1, 2021, or to submit a change in coverage.
• 2021 Small Group Enrollment Application/Change Form 
  Use this form to apply for small group coverage effective January 1, 2021.
• 2021 Large Group Enrollment Application/Change Form 
  Use this form to apply for large group coverage effective January 1, 2021.
• Individual Plan Responsible Party Form (Child-Only Policy) 
  Please fill out this form if you have applied for a child-only policy but did not specify the policy owner. Use this form to tell BCBSMT that you will be the responsible party/policy owner for the child-only policy.
• 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.

Pharmacy

• PrimeMail Prescription Order Form 
• Prime Prescription Drug Claim Form 
• Ridgeway Prescription Drug Mail-Order Form 

Group Specific Forms

• RCCH Healthcare Partners: Out-of-Network Exception Request Form 
  RCCH Healthcare Partners Employees must complete an out-of-network exception request form prior to services performed.
• MUS Faculty/Staff Vision Claim Form 
• MUST Immunization Submission Form 
• MUS Faculty/Staff Massage Therapy Claim Form 
• PayneWest Massage Therapy Claim Form 
• Ranch and Home Supply Massage Therapy Claim Form 
• Marcus Daly Memorial Hospital Out of Network Exception Request Form 
• Marcus Daly Memorial Hospital Vision Claim Form 

BLUE VALUE^sm TOTAL HEALTH MANAGEMENT

THM is an innovative wellness program offered exclusively to BCBSMT group clients, and is only available to members of group plans that offer the program as part of their benefit plan. THM uses sound clinical guidelines, specific goals, and effective incentives to help achieve results. Members work with a primary care provider to achieve specific goals. If you have any questions, email TotalHealthManagement@bcbsmt.com.

• Employee Sponsored Wellness Participation Notice and Consent Form 
• THM Assessment Form  
• Member Score Calculator  
• Frequently Asked Questions (FAQs directed toward members)  
• Definitions of Health and Incentive Metrics