Jump to Content
Learn moreProvider Supply Forms
BCN Providers
The following forms are for Blue Care Network providers only. If you wish to participate with either Blue Cross Blue Shield of Michigan or Blue Care Network, please go to Enrollment.
Dental Providers
Blue Cross Blue Shield of Michigan accepts claims on the 2006 and 2002, 2004 American Dental Association form. Call the ADA at 800-947-4746 to order the form.
BCBSM offers a self-addressed envelope, Form No. 2685, for returning dental claim forms. Use the Professional & Facility Provider Supply Requisition Form (PDF) to order a supply. Complete the form and mail or fax it to us using the contact information provided.
Vision & Hearing Providers
Blue Cross Blue Shield of Michigan will provide many of the supplies you need to prepare and submit vision claims. The items listed below are some of the supplies that you can order using the Professional & Facility Provider Supply Requisition Form (PDF). Complete the form and mail or fax to us using the contact information provided.
- No Cost Items
- BCBSM self-addressed envelopes for returning claim forms (CS 5129)
- Michigan health benefits claim review (CC 6742)
- For Sale Items
- CMS-1500 two-ply continuous feed claim form ($40.67/1,000 forms)
- CMS-1500 two-ply snap out claim form ($20.88/500 forms)
- CMS-1500 one-ply continuous feed claim form ($15.61/1,000 forms)
