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.