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Coordination of Benefits Form

Who is this for?

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 members to tell us whether you, your spouse or any of your covered dependents have health insurance through another company, including Medicare.

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.

BLUE CROSS BLUE SHIELD OF MICHIGAN members (PPO/Traditional)