Change of Status 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).