Dental Service Claim Form
Who is this for?
If you're a Blue Cross Blue Shield of Michigan member, use this form to ask for reimbursement for dental 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 dentist that doesn’t accept your insurance.
If you’re insured through Blue Cross Blue Shield of Michigan, you can use the Member Application for Payment Consideration form to ask us for reimbursement.
This form is only for dental service claims.
If you have any questions, call the phone number on the back of your enrollee ID card and we’ll help.
What you’ll need:
- Your enrollee ID card
- A printer to print the form
- Original receipts from your doctor, dentist, etc.
- A copier or scanner to make a copy of each receipt for yourself
- An envelope and postage to mail the form