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Blue Care Network Physician Selection Form for Employer-Sponsored Plans

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're enrolling in a Blue Care Network group plan, use this form to choose your primary care physician.

You can choose a different primary care physician for each member of your family, or one to care for your entire family.

If you have any questions, please contact your employer.

Access the form here: Blue Care Network Primary Care Physician Selection form (PDF)

What you’ll need:

  • A printer to print the form 
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

Step by step instructions:

  1. Select your primary care physician. If you need help finding one, our Find a Doctor tool has a list of doctors that participate in Blue Care Network. 
  2. Fill out the form completely. Check with your employer to find out if you should return the form to them first before mailing it to us. 
  3. Complete the form, sign and return it to us along with your Subscriber New Enrollment form. Return this form as soon as you enroll so that we can notify your doctor of your membership.

Fax or mail the form to:

Membership and Billing – M.C. C411
Blue Care Network
P.O. Box 5043
Southfield, MI 48086

Fax: 1-877-218-1466

You can also do this online by logging in to your account at bcbsm.com. See How can I choose or change my primary care physician online for more information.

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