Qualification Forms
Who is this for?

If you're a Blue Cross Blue Shield of Michigan member with a health plan that requires a qualification form, you'll need to fill out one of these forms with your doctor.
Healthy Blue Achieve Form
If you have our Healthy Blue Achieve plan, this qualification form (PDF) is for you. To get your financial incentive, you'll need to fill it out with your doctor. Your doctor will submit the form by following the instructions on the back.
Standard Qualification Forms
If you have a Blue Cross Blue Shield of Michigan plan other than Healthy Blue Achieve that requires a qualification form, please choose from the forms below. Your doctor will submit the form by following the instructions on the back.
- Michigan doctors: Physician Qualification Form (PDF)
- Out-of-state doctors: Physician Qualification Form (PDF)
What you’ll need:
- Your enrollee ID card
- A printer to print the form
- An appointment with your doctor to fill out the forms. Information will be needed from both you and your doctor.
If you have any questions, please contact us.
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