ENROLLMENT FORM
Use this form to enroll eligible new employees, current employees who become eligible based on hours worked, or current eligible employees who previously waived and have either a HIPAA qualifying special event or open enrollment.

AFFIDAVIT OF DOMESTIC PARTNERSHIP

Use this form to submit verification of a domestic partner.

MEDIMPACT PHARMACY CLAIM FORM

Use this form for reimbursement of pharmacy claims paid.

CHANGE FORM
Use this form to make changes to current employee coverages such as enroll a newborn, drop a spouse, or change an address.

TOTAL HEALTH MANAGEMENT (THM) FORM

Use this form to participate in the Wellness Program.

INTERNATIONAL TRAVEL INFORMATION

This flyer provides information that the member can take while living or traveling abroad.

WAIVE FORM
Use this form to keep a record of all eligible employees who choose to waive group coverage.

BCBSMT CLAIM FORM ( Employees )

Use this form for reimbursement of medical claims paid.

INTERNATIONAL CLAIM FORM

Use this form to file an international claim.