Automatic Payment Form Purpose of form: Provides a format for automatic payments on your policy. Download Direct Premium Request Form Purpose of form: A form for New Mexico licensed insurers to report the total direct premiums written in New Mexico for accident and health insurance for calendar year 2016. Download PHI Release Authorization Form Purpose of form: Authorizes release of personal health information (PHI) for a member. Download Non-Tobacco User Affidavit Purpose of form: A form to declare if a member presently smokes or uses tobacco products, nor (ii) have smoked or used tobacco products at any time during the 12 months immediately preceding the date of the affidavit. Download For further information and assistance regarding Forms please contact Customer Service at 1-844-728-7896.