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Medical Treatment History Request Form

Who is this for?

If you're a Blue Cross Blue Shield of Michigan member, use this form if you've had payments for medical services rejected for a pre-existing condition and wish to have us reconsider for payment as not pre-existing.

Access the form here: Medical Treatment History Request Form (PDF)

What you’ll need:

Your enrollee ID card.
A printer to print the form.
Copies of all medical records, including a list of medications you’ve taken, for the last six months related to the services you list in Part 1 of this form.
An envelope and postage to mail the form, or a fax machine. This form includes instructions on where to send it.
A copy of Part 2 of the form to be completed by your doctor(s).

If you have any questions, please contact us.