Subscriber New Enrollment Form
For members with employer-sponsored health care plans
If you have any questions while filling out the form, please contact your employer. They should be able to tell you what your next steps are.
Subscriber New Enrollment and Change of Status form (PDF)
Anytime you enroll in a new plan, you'll need to fill out the form and send it to us. Please follow our instructions, and mail or fax it in.
Fax or mail the form to:
Membership and Billing – M.C. J202
Blue Cross Blue Shield of Michigan
P.O. Box 312260
Detroit, MI 48231-2260
Fax: 1-866-900-2619 or 1-866-900-2829
Fax or mail the form to:
Membership and Billing – M.C. J207
Blue Care Network
P.O. Box 44257
Detroit, MI 48244-0257
Fax: 1-877-218-1466
Fax or mail the form to:
Membership and Billing – M.C. J202
Blue Cross Blue Shield of Michigan
P.O. Box 312260
Detroit, MI 48231-2260
Fax: 1-866-900-2619 or 1-866-900-2829
Fax or mail the form to:
Membership and Billing – M.C. J207
Blue Care Network
P.O. Box 44257
Detroit, MI 48244-0257
Fax: 1-877-218-1466