HSA Employer Setup Form – Benefit Wallet ® – Submit an electronic copy of this form for each employer wishing to elect HSA integration with BenefitWallet.īenefit Wallet ® Benefits Design Guide for FSA, HRA and Commuter Spending Accounts – Submit an electronic copy of this form for each employer wishing to elect FSA integration with BenefitWallet. Group Enrollment Application/Change Form – SpanishĢ022 Enrollment Package – includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and afterĢ022 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after Ģ022 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after use this form to amend the original BPAĢ021 Benefit Program Application (BPA) for New Small Groups 2-50 – for new accounts effective on or after Ģ021 Benefit Program Application (BPA) Amendment for Small Groups 2-50 – for renewing accounts with anniversary dates on or after use this form to amend the original BPAĮmployer Group Information (EGI) Form – this form must be submitted with the BPAĪway From Home Care Guest Membership Application Group Enrollment Application/Change Form – use this form to apply for group coverage or make changes to an existing BCBSNM policy ![]() Enrollment Forms for New Small Groups Form Name
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