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Authorization Agreement for Automatic Payments Form

Who is this for?

If you're a Blue Care Network member, use this form to have your health insurance payments automatically deducted from your personal checking or savings account.

Access the form here: Authorization Agreement for Automatic Payments 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 Care Network
    IAA/Billing Department - Mail Code C415
    P.O. Box 5043
    Southfield, MI 48086

If you have any questions, please contact us.