Member Forms & Other Resources
Below are forms that a New Mexico Health Connections member may need over the course of his or her membership with the plan.
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ACH Form (for recurring monthly payments via bank draft)
Appeal/Complaint Request & Assignment of Authorized Representative Form
Authorization to Release Protected Health Information (PHI)
Coordination of Benefits (Other Insurance Coverage) Form
Continuity of Care Form
Coverage Change Form (Adding dependents, cancelling coverage, etc.)
Drug Prior Authorization Request Form (You may begin your drug prior authorization request here. Download and print the form and give it to your provider to complete. Your provider will send the completed form to us.)
Fraud, Waste, and Abuse Report Form
Healthy Check-Up Interview Form
Member Medical Claim Reimbursement Form
Member Pharmacy Reimbursement Form
Pharmacy Mail Order Form
Subrogation (Accident/Injury) Referral Form
Transition of Care Form
Transplant Travel Benefit Description
Transplant Travel Expense Form
If you are looking for a form that is not included on this page, please contact Customer Service at 1-855-7MY-NMHC.