Blue Care Network Individual Member Change of Status Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Care Network member, use this form to let us know of any changes to your status, like address changes, name changes or adding people to your policy.

We want you to receive all the benefits you are entitled to, so it is important to keep your records accurate. If you're an individual health care plan member (you don't get your health insurance through an employer), use this form to tell about:

  • Address changes
  • Name changes
  • Spouses or dependents that need to added or removed
  • Coverage changes

If you have any questions, call the Customer Service number on the back of your enrollee ID card.

Access the form here: Blue Care Network Individual Member Change of Status form (PDF)

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form 
  • An envelope and postage to mail the form, or a fax machine.

Complete the form and return it to us within 30 days of the change. Then fax or mail the form to:

Membership and Billing – Mail Code C411
Blue Care Network
P.O. Box 5043
Southfield, MI 48086

Fax: 1-877-218-1466