Member Secured Services

Member Forms

• Automatic Payment Plan Enrollment Form (PDF) — Individual and direct billed subscribers can enroll to have their health insurance payments automatically deducted from a personal checking or savings account. Simply complete the enrollment form and mail it to the address indicated.


• Coordination of Benefits — Use this form to list everyone covered on your BCBSM contract, and any additional health care coverage each person has, including Medicare.
  • Online Form
  • Coordination of Benefits Form (PDF)
• Blue Cross Blue Shield of Michigan Qualification Form — The Blue Cross Blue Shield of Michigan Qualification Form is for you and your physician to complete. Be sure to submit the form in time to meet your plan's deadline.
  • Qualification Form (PDF)

Prescription Drug Claim Forms

• Medco Prescription Drug Direct Member Reimbursement forms – If filling out online, print, sign and mail with original receipts to the address on page two of the form.
  • Auto/National - Use this form if your BCBSM identification card has the Medco logo and Rx group number BCBSMAN.
  
  
  • For services prior to July 1, 2010, please mail a copy of your itemized pharmacy receipt along with a copy of your BCBSM identification card to your BCBSM customer service department
  
  
  • Local (For July 1 claims and thereafter) – Use this form if your BCBSM identification card has the Medco logo on the back and RxGRP: BCBSMRX1 on the front. Use this form with itemized receipts to request reimbursement for covered drugs for prescriptions purchased on or after July 1, 2010.
• Mail Order forms:
  • Auto/National group Mail Order request form (PDF) - Use this form to order your non-specialty drugs via mail order through Medco if your BCBSM identification card has the Medco logo and RxGRP: BCBSMAN.
  
  
  • Local group Mail Order request form (PDF) – Use this form to order your non-specialty drugs via mail order through Medco if your BCBSM Identification card has the Medco logo and RxGRP: BCBSMRX1.
  
  
  • Walgreens Specialty Pharmacy Mail Order request form (PDF) – Use this form to order specialty drugs only via mail order through Walgreens Specialty Pharmacy. Not sure if your prescription medications are specialty drugs? Visit the Specialty Pharmacy Program page to learn more.

• Master Medical Claim Form (PDF) — Use this form with itemized receipts to request reimbursement for paid services.


• Member Application for Payment — Use these forms with original itemized receipts to request benefit payment consideration for services that were paid directly to a nonparticipating provider.
  • Medical, Vision and Hearing Services
  • Metabolic Diseases and Foods (PDF)
  • Dental Services (PDF)
• New Enrollment/Change of Status Form — Print this form for mailing/FAX.
  • New Enrollment/Change of Status Form — October 2010 — English Version (PDF)
  • New Enrollment/Change of Status Form — Spanish Version (PDF)
  • Instructions — New Enrollment/Change of Status — Spanish Version (PDF)
• Individual — Change of Status Form (PDF) — Use this form if you are an individual-billed member who wants to notify BCBSM of changes relating to membership, coverage or name, address or telephone information.


• Application for Waiver of the Pre-existing Waiting Period (PDF) — Use this form if you are an individual member who qualifies for a waiver of the 180-day pre-existing condition exclusion period.


• Privacy Forms — This page provides the forms necessary to exercise your rights under the HIPAA Privacy rule (for example, to authorize BCBSM or BCN to discuss your private health information with someone else on your behalf, to request confidential communications, to register a privacy complaint, etc.)