Browse by Topic

Browse by Plan Type

Other Help

Not finding what you need in this section for members and insurance shoppers? Check out our other help sections below.

Blue Care Network Member Reimbursement Form

Who is this for?

box-icon-HMO

If you're a Blue Care Network member, use this form to ask for reimbursement for medical services you've had to pay for yourself.

Even when you have health insurance, there may be occasions when you have to pay for services yourself. For example, you have to see an out-of-network doctor who doesn’t accept your insurance.

If you're a Blue Care Network member, you can use the Member Reimbursement Form to ask us to pay you back for medical services.

If you have any questions, call the phone number on the back of your enrollee ID card and we’ll help.

Blue Care Network Member Reimbursement Form (PDF)

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • Original receipts for the services you received
  • A copier or scanner to make a copy of each receipt for yourself
  • An envelope and postage to mail the form

Be sure to include:

  • An itemized bill 
  • Original proof of payment
  • Original receipts for the services you received
  • The treatment record or emergency report 

What to do:

  1. Print a copy of the Blue Care Network Member Reimbursement Form (PDF)
  2. Fill out and sign the form.
  3. Send the completed form and all supporting materials to:

P.O. Box 68767
Grand Rapids, MI 49516-8767

Was this content helpful?

Rate it

Submit >

One site. One stop.

Managing your health plan online
has never been easier. On the new bcbsm.com, all your account information is in one place and personalized, so it's more useful.
Even better, you can access it anytime, anywhere, from your mobile device.

I’d like to register

Log in to my account

©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.

Site Map  |  Feedback  |  Important Legal and Privacy Information

Explanation of Level A Conformance
Better Business Bureau Online Seal of Reliability