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If you are a Blue Cross Blue Shield of Michigan member with a health plan requiring a qualification form, give this form to your doctor to fill out.

If your health insurance plan requires this form, both you and your doctor will need to fill it out.

What you’ll need:

Your enrollee ID card
A printer to print the form
You will need to make an appointment to have your doctor fill out part of this form
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.