Automatic Payment Form

Purpose of form: Provides a format for automatic payments on your policy.

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.

PHI Release Authorization Form

Purpose of form: Authorizes release of personal health information (PHI) for a member.

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.

For further information and assistance regarding Forms please contact Customer Service at 1-844-728-7896.