Forms library
Blue Care Network forms
Enrollment forms
- PersonalPlus Enrollment form (PDF)
- Authorization Agreement for Automatic Payments form (PDF)
- BCN Individual Change of Status Form (PDF)
Benefit management forms
- Online Coordination of Benefits form
– For online updating of COB information - Coordination of Benefits Questionnaire (PDF)
– To print and then mail or fax to update COB information - Member Reimbursement form (PDF)
– For medical claims that you’ve paid - Member Billing form (PDF)
– For medical claims that need to be paid - Physician Selection form (PDF)
– To print and then mail or fax to change your PCP - Medco Health Home Delivery
Pharmacy Service Order Form (PDF)
– To mail order prescription drugs - Medco Prescription Drug Reimbursement Form (PDF)
– For prescription drug claims that you’ve paid - BlueCard Worldwide International Claim Form
– For out-of-state medical claims that you’ve paid
Advance directive forms
- Acceptance by Patient Advocate form ( PDF)
- Durable Power of Attorney for Health Care form (PDF).
- Patient’s Advance Directive form (PDF)
Protected health information and privacy request forms
These forms may be used to exercise your rights for the handling of your personal information as described in the Blue Cross Blue Shield of Michigan and Blue Care Network HIPAA Notice of Privacy Practices (PDF).
For each form, fill in all information requested, print and mail to the address listed at the bottom of the specific form. Read the instructions on the form as some of them may be faxed to BCBSM.
- Authorization
for Use and Disclosure of Protected Health Information (PDF)
Use this form to authorize BCBSM or BCN to release your protected health information to a person or entity of your choice. - Authorization for Use and
Disclosure of Psychotherapy Notes (PDF)
Use this form to authorize BCBSM or BCN to release your psychotherapy notes to a person or entity of your choice. - Authorization to Revoke a Previous
Authorization (PDF)
Use this form when you no longer authorize BCBSM or BCN to disclose your protected health information to the person or entity you asked us to send information to under your previous authorization release. - Request for Access to
Designated Protected Health Information Records (PDF)
Complete this form to request access to specific information that we maintain about you. - Request to Amend Protected Health
Information (PDF)
Complete this form to request an amendment of the information we maintain about you. - Request for
Restriction of Use and Disclosure of Protected Health Information (PDF)
Use this form to request restrictions on the way in which we use or disclose your health information. - Request for Alternate Means of Confidential
Communications (PDF)
Complete this form to request that we communicate with you about your protected health information using an alternative address or means of communication. - Revocation of Alternate Means of
Confidential Communications (PDF)
Use this form when you no longer want BCBSM or BCN to communicate with you about your protected health information using the alternative address or means of communication you previously provided to us. - Request for List of Disclosures
of Protected Health Information (PDF)
Complete this form to request a listing of the specific disclosures of your health information that we have made to others. - Affidavit of Next of Kin — for handling of decedent's health care claim payments (PDF)
Use this form when no probate estate will be established for a deceased member. In the form, you will attest that you are the nearest relative of a deceased Blues member and responsible for handling health care bills and payments on the member's behalf. If a probate estate has been established, please send a copy of the court-approved letter of authorization naming you as personal representative. - Health Care Privacy Practices Complaint Form (PDF)
Complete this document to make a complaint about our privacy practices or our compliance with our notice of privacy practices. Alternatively, you can call our Privacy Complaint Line at 1-800-552-8278 or file your complaint directly with the Office for Civil Rights at the following address:Office for Civil Rights
Or contact them at 312-886-2359, TDD 312-353-5693 or Fax 312-886-1807.
U.S. Department of Health & Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
page modified 09/23/2011