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State of Michigan Claim Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a State of Michigan member insured through Blue Cross Blue Shield of Michigan, use this form to ask for reimbursement for medical, hearing and vision 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 that doesn’t accept your insurance.

If you’re a State of Michigan member, you can use the Member Application for Payment Consideration form to ask us for reimbursement. Use it for medical, hearing and vision services.

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
  • A copier or scanner to make a copy of each receipt for yourself
  • An envelope and postage to mail the form

State of Michigan Member Application for Payment Consideration (PDF)

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