Helpful forms
Enrollment forms
Are you interested in participating with Blue Cross Complete of Michigan? If so, complete the appropriate form below:
Provider Enrollment Form (PDF)
Provider Enrollment Collaborating Supervising Physician Form (PDF)
Provider Enrollment Cultural Competency Attestation Form (PDF)
Provider Enrollment CSHCS Physician Attestation Form (PDF)
Provider Enrollment Disclosure Questions (PDF)
Provider Enrollment Practicing Locations (PDF)
Facility Enrollment Form (PDF)
Non-Clinical Health Worker Enrollment Form (PDF)
Recuperative Care Enrollment Form (PDF)
FQHC credentialing guidelines (PDF)
Federal Qualified Health Centers should follow the FQHC credentialing guidelines.
Change forms
If you are already enrolled but need to change things such as provider name, contact information, office hours, panel status, or hospital affiliations, please fill out the Provider Change Form.
Provider Change Form (PDF)
Where to submit forms
Submit forms using one of the following contact methods:
Blue Cross Complete of Michigan
Attention: Provider Network Operations
4000 Town Center, Suite 1300
Southfield, MI 48075
Email: bccproviderdata@mibluecrosscomplete.com
Fax: 1-855-306-9762
Blood lead test forms
Blood Lead Test Requisition form DCH-0696 (PDF)
Use this form to submit blood specimens for blood lead testing to the Michigan Department of Health and Human Services.
Blood Lead Results Reporting form MSA-1532 (DOC)
Use this form to report additional blood lead results, not previously reported to the Michigan Department of Health and Human Services.
Other MDHHS forms
Acknowledgement of Receipt of Hysterectomy Information (PDF)
Use this form to confirm that a patient has received and understands hysterectomy information prior to a procedure.
Beneficiary Verification of Coverage MSA – 1550 (PDF)
Use this form to confirm that a patient understands payment coverage for an elective abortion under limited circumstances.
Consent for Sterilization (PDF)
Use this form to confirm that a patient understands and consent to sterilization.
Certification for Induced Abortion (PDF)
Use this form to certify that a patient understands that their life would be endangered if the pregnancy were continued or cases in which the pregnancy was the result of rape or incest.
Clinical Specimen Shipping Units Requisition form DCH-0568 (DOTX)
Use this form to ship clinical specimens to the Michigan Department of Health and Human Services.
Contact MDHHS
Michigan Department of Health & Human Services
333 S. Grand Ave
P.O. Box 30195
Lansing, Michigan 48909
Enrollment forms
Are you interested in participating with Blue Cross Complete of Michigan? If so, complete the appropriate form below:
Provider Enrollment Form (PDF)
Provider Enrollment Collaborating Supervising Physician Form (PDF)
Provider Enrollment Cultural Competency Attestation Form (PDF)
Provider Enrollment CSHCS Physician Attestation Form (PDF)
Provider Enrollment Disclosure Questions (PDF)
Provider Enrollment Practicing Locations (PDF)
Facility Enrollment Form (PDF)
Non-Clinical Health Worker Enrollment Form (PDF)
Recuperative Care Enrollment Form (PDF)
FQHC credentialing guidelines (PDF)
Federal Qualified Health Centers should follow the FQHC credentialing guidelines.
Change forms
If you are already enrolled but need to change things such as provider name, contact information, office hours, panel status, or hospital affiliations, please fill out the Provider Change Form.
Provider Change Form (PDF)
Where to submit forms
Submit forms using one of the following contact methods:
Blue Cross Complete of Michigan
Attention: Provider Network Operations
4000 Town Center, Suite 1300
Southfield, MI 48075
Email: bccproviderdata@mibluecrosscomplete.com
Fax: 1-855-306-9762
Blood lead test forms
Blood Lead Test Requisition form DCH-0696 (PDF)
Use this form to submit blood specimens for blood lead testing to the Michigan Department of Health and Human Services.
Blood Lead Results Reporting form MSA-1532 (DOC)
Use this form to report additional blood lead results, not previously reported to the Michigan Department of Health and Human Services.
Other MDHHS forms
Acknowledgement of Receipt of Hysterectomy Information (PDF)
Use this form to confirm that a patient has received and understands hysterectomy information prior to a procedure.
Beneficiary Verification of Coverage MSA – 1550 (PDF)
Use this form to confirm that a patient understands payment coverage for an elective abortion under limited circumstances.
Consent for Sterilization (PDF)
Use this form to confirm that a patient understands and consent to sterilization.
Certification for Induced Abortion (PDF)
Use this form to certify that a patient understands that their life would be endangered if the pregnancy were continued or cases in which the pregnancy was the result of rape or incest.
Clinical Specimen Shipping Units Requisition form DCH-0568 (DOTX)
Use this form to ship clinical specimens to the Michigan Department of Health and Human Services.
Contact MDHHS
Michigan Department of Health & Human Services
333 S. Grand Ave
P.O. Box 30195
Lansing, Michigan 48909