New Enrollment and Change of Status Form
Who is this for?
If you're enrolling employees in a group health insurance plan or making changes to an existing plan, use this form.
This file contains three important forms for employees that you can download and print:
- The form to enroll in a health insurance plan through either Blue Cross Blue Shield of Michigan or Blue Care Network
- The form to choose a primary care physician (for employees enrolling in Blue Care Network plans)
- The change of status form (used to update information, such as add someone to a contract, change an address, etc.) for employees with Blue Cross Blue Shield of Michigan or Blue Care Network plans
Access the form here: New Enrollment and Change of Status form (PDF)
You can also get the New Enrollment and Change of Status form in Spanish (PDF).