Change of Status Form

Who is this for?

The Change of Status Form can be used to update information for employees with Blue Cross Blue Shield of Michigan or Blue Care Network plans.

If you're enrolling employees in a group health insurance plan or making changes to an exisiting 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).

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