Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, check all applicable boxes to indicate your enrollment event. If you are a new enrollee or adding a dependent, complete all relevant sections.
3. Provide your personal details in Section 2, even if you are declining coverage. Ensure accuracy in your Social Security number and contact information.
4. In Section 3, select your coverage options. Enter the seven-character plan ID for your chosen benefit design.
5. Complete Section 4 with information about yourself and each dependent. Include names, Social Security numbers, and any changes to primary care physicians if applicable.
6. If applicable, fill out Sections 5 through 8 regarding disabled dependents, other coverage information, Medicare coverage details, or declination of coverage.
7. Finally, sign and date Section 9 to agree to the conditions set forth before submitting the form to your employer’s Enrollment Department.

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