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Blue Care Network Member Reimbursement Form

Who is this for?


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

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