Change of Status Form

For members with employer-sponsored health care plans

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and you have an employer-sponsored plan, use this form to let us know of any changes to your status, like address or name changes.

The purpose of this form is to help members of an employer-sponsored insurance plan update us when they have any changes to their status such as:

  • Address changes
  • Name changes
  • Adding or removing spouses or dependents
  • Health savings and flexible spending account changes

Please contact your employer to see if you need to update your address or policy information with them first before filling out the Change of Status form. If you have any questions, call the Customer Service number on the back of your ID card or contact your employer.

Access the form here: Change of Status Form (PDF)

What you’ll need:

  • Your member health insurance ID card
  • A computer [optional] with Internet if you wish to fill out the electronic form
  • A printer to print the form 
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

Step by step instructions:

  1. On the top of the form, let us know which plan you are enrolled in by checking the box for either Blue Cross Blue Shield of Michigan or Blue Care Network member. 
  2. There are three sections to this form – subscriber information, coordination of benefits information and health savings and flexible spending account options. 
    • Subscriber information:  Fill out this portion with your social security number and your updated name, address or telephone number. Also, let us know if you want to add or remove a spouse or children (dependents).
    • Coordination of benefits information: Fill out this portion if you want to let us know that your spouse or dependent has health insurance through another company.
    • Health savings and flexible spending account options: Fill out this portion if you want to add, change or cancel a health savings or flexible spending account.
  3. The last section of the form, "Employer/Group use only" is for your employer to fill out. You may want to check with your employer to find out if you should return the form to them first so that they may fill out their portion before mailing it to us. 
  4. Complete the form and return it to us within 30 days of the change. You may choose to make changes to the online form, then print; or print the form first then fill it out. You may fax or mail the form to:

For Blue Cross Blue Shield of Michigan members

Membership and Billing – M.C. 610G
Blue Cross Blue Shield of Michigan
P.O. Box 2260
Detroit, MI 48231-2260

Fax: 1-866-900-2619 or 1-866-900-2829

For Blue Care Network members

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

Fax: 1-877-218-1466

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