Forms

Here are forms you may need related to your health care coverage through the UAW Retiree Medical Benefit Trust. If you can't find a form or have a question, call the Customer Service number on the back of your enrollee ID card and we'll help.

Would you like a representative to talk to your group about their health care coverage?

Use this form: Request for Presentation Speaker/Attendance by UAW Trust and/or Health Plan Representative (PDF)

Privacy forms

These forms are for managing protected health information. That's what Blue Cross Blue Shield of Michigan calls your private medical information we have on file.

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

Use this form to tell us it's okay to let someone see your protected health information.

Use this form to tell us it's okay to let someone see your psychotherapy notes.

Use this form to tell us you want to stop letting someone you previously approved see your information.

©1996-2014 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. We provide health insurance in Michigan.

State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

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