Member Secured Services

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Member Forms

• Automatic Payment Plan Enrollment Form (PDF) — Individual and direct billed subscribers can enroll to have their health insurance payments automatically deducted from a personal checking or savings account. Simply complete the enrollment form and mail it to the address indicated.


• Coordination of Benefits — Use this form to list everyone covered on your BCBSM contract, and any additional health care coverage each person has, including Medicare.
  • Online Form
  • Coordination of Benefits Form (PDF)
• Mail Order Prescription Drug Requests:
  • Option Care Mail Order request form (PDF) — Use this form to order specialty drugs only via mail order through Option Care. Not sure if your prescription medication are specialty drugs? Visit the Specialty Pharmacy Program page to learn more.
  
  
  • Medco By Mail Order request form (PDF) — Use this form to order your non-specialty drugs via mail order through Medco. To use this form, your BCBSM Identification card should have the DRAMS logo in the lower right hand corner for prescription drugs.
• Master Medical Claim Form (PDF) — Use this form with itemized receipts to request reimbursement for paid services.


• Medco Payment to Subscriber Claim form (PDF) — Use this form with itemized receipts to request reimbursement for covered drugs from a participating pharmacy. To use this form, your BCBSM Identification card should have the Medco logo and Rx group number BCBSMAN in the lower right hand corner.


• Member Application for Payment — Use these forms with original itemized receipts to request benefit payment consideration for services that were paid directly to a nonparticipating provider.
  • Medical, Vision and Hearing Services (PDF)
  • Dental Services (PDF)
• New Enrollment/Change of Status Form — Print this form for mailing/FAX.
  • New Enrollment/Change of Status Form — Apr 08 — English Version (PDF)
  • New Enrollment/Change of Status Form — Spanish Version (PDF)
  • Instructions — New Enrollment/Change of Status — Spanish Version (PDF)
• Individual — Change of Status Form (PDF) — Use this form if you are an individual-billed member who wants to notify BCBSM of changes relating to membership, coverage or name, address or telephone information.


• Payment to Subscriber Pharmacy Claim Form (PDF) — Use this form with itemized receipts to request reimbursement for covered drugs received from a participating pharmacy. To use this form, your BCBSM Identification card should have the DRAMS logo in the lower right hand corner for prescription drugs.


• Privacy Forms — This page provides the forms necessary to exercise your rights under the HIPAA Privacy rule (for example, to authorize BCBSM or BCN to discuss your private health information with someone else on your behalf, to request confidential communications, to register a privacy complaint, etc.)