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Automatic Payment Plan Enrollment Form

Who is this for?

If you are a Blue Cross Blue Shield of Michigan member, use this form to have your health insurance payments automatically deducted from your personal checking or savings account.

Access the form here: Automatic Payment Plan Enrollment Form (PDF)

What you’ll need:

Your enrollee ID card
A blank, voided check for the account from which you want 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.

Mail the form to:

    Blue Cross Blue Shield of Michigan
    P.O. Box 2467
    Detroit, MI 48231-2467

Or you can fax the form to 313-983-2605.

If you have any questions, please contact us.