Jump to Content
Group Forms
- Application for consideration to serve on the board of directors or on the Nongroup Subscriber Director Selection Council (PDF)
- Application for consideration to serve on the board of directors or on the Small-Group Subscriber Director Selection Council (PDF)
- Blue Care Network Group Forms/Brochures/Flyers Fax Form (PDF) — Use this form to order BCN group forms, brochures, or flyers.
- 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.
- Domestic Partner affidavit (PDF) — Use this form to declare domestic partner status .
- Employee Waiver Form (PDF) — Use this form to waive company benefits.
- BlueHealthConnection® Healthy Blue IncentivesSM Paper Health Assessment Request Form — Employers should use this form to request paper health assessments for Healthy Blue Incentive members. (PDF)
- 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.
- New Enrollment/Change of Status Form — Print this form for mailing/FAX.
- Notice of Privacy Practices (PDF) — Provides details regarding our privacy practices and your rights with respect to the handling of personal information.
- 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.
- Payment to Subscriber Pharmacy Claim Form (PDF) — Use this form with itemized receipts to request reimbursement from Medco for covered drugs from a participating pharmacy purchased on or after July 1, 2010.
- Privacy Forms — This page provides documents related to our privacy practices.
