Blue Care Network Member Reimbursement Form

Even when you have health insurance, there may be occasions when you have to pay for services yourself. For example, you have to see an out-of-network doctor who doesn’t accept your insurance.

If you're a Blue Care Network member, you can use the Member Reimbursement Form (PDF) to ask us to pay you back for medical services.

If you're in a religiously accommodated group and you paid for your own contraceptive prescription or service, you can get reimbursed using the Contraceptive Accommodation Choice Enrollment Form (PDF).

If you have any questions, call the phone number on the back of your subscriber ID card, formerly known as enrollee ID, and we’ll help.

Be sure to include:

• An itemized bill
• Original proof of payment
• Original receipts for the services you received
• The treatment record or emergency report

What to do:

Print a copy of the Blue Care Network Member Reimbursement Form (PDF).

Fill out and sign the form.

Send the completed form and all supporting materials to: 

Blue Care Network
P.O. Box 68767
Grand Rapids, MI 49516-8767

Or fax your forms and supporting materials to 1-866-637-4972.