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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 that requires a qualification form, you'll need to fill out one of these forms with your doctor.

Healthy Blue Achieve Form

If you have our Healthy Blue Achieve plan, this qualification form (PDF) is for you. To get your financial incentive, you'll need to fill it out with your doctor. Your doctor will submit the form by following the instructions on the back.

Standard Qualification Form

If you have a Blues plan other than Healthy Blue Achieve that requires a qualification form, our standard qualification form (PDF) is for you. Your doctor will submit the form by following the instructions on the back.

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.

If you have any questions, please contact us.

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