Coordination of Benefits Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and FormsMichigan Health Insurance – Customer Service – Documents and Forms

If you are a Blue Cross Blue Shield of Michigan or Blue Care Network member, use this form to tell us whether you have other health insurance besides ours.

We use this form to ask you whether you, your spouse or any of your covered dependents have health insurance through another company.

By coordinating your benefits we can work with the other insurance company to make sure that your claims are paid with the least amount of hassle to you. Just select your plan type below to get started.

Note: If you don’t have additional health insurance, we ask that you let us know by filling out that part of the form.