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Qualification Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Cross Blue Shield of Michigan member with a health plan and that requires a qualification form, you'll need to fill out one of these forms with your doctor.

Healthy Blue Achieve and Healthy Blue Outcomes Form

If you have our Healthy Blue Achieve or Healthy Blue Outcomes plan, this qualification form is for you. To get your financial incentive, you'll need to fill it out with your doctor and fax it to the number listed on the form.

Standard Qualification Form

If you have another Blues plan other than Healthy Blue Achieve or Healthy Blue Outcomes that requires a qualification form, our standard qualification form is for you. You'll need to fill it out with your doctor and fax it to the number listed on the form. 
 

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • An appointment with your doctor to fill out the forms. Information will be needed from both you and your doctor.
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions on where to send it.

    If you have any questions, please contact us.

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