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Automatic Payment Plan Enrollment Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you have an individual and family health care plan with us, use this form to have your premium payments automatically deducted from your personal checking or savings account.

What you’ll need:

  • Your Blues ID card
  • Your account number
  • A blank, voided check for the account from which you would like to withdraw your payments
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions on where to send it.
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Did you know? When you enroll in eBilling, your statements will be paperless.

If you have any questions, please contact us.

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