Appeal Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you have a problem with your Blue Cross Blue Shield of Michigan service, you can use this form to file an appeal with us.

If you're a Blue Cross Blue Shield of Michigan member and are unable to resolve your concern through Customer Service, we have a formal grievance and appeals process. You can use this form to start that process. The form is optional and can be used by itself or with a formal letter of appeal.

If you have any questions, call the phone number on the back of your Blue Cross ID card and we'll help.

What you'll need:

  • Your Blue Cross ID card
  • A printer to print the form
  • Original receipts from your doctor
  • A copier or scanner to make a copy of each receipt for yourself
  • An envelope and postage to mail the form

Member Appeal Form (PDF)