Subscriber New Enrollment Form
For members with employer-sponsored health care plans
Who is this for?
Use this form if you are enrolling in a new employer-sponsored health care plan.
If you have any questions while filling out the form, please contact your employer.
Access the form here: Subscriber New Enrollment and Change of Status form (PDF)
What you’ll need:
- 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:
- On the top of the form, let us know what type of health insurance provider you will be enrolling in by checking the box for either Blue Cross Blue Shield of Michigan or Blue Care Network member.
- If you are a Blue Care Network member, you will also need to fill out the Blue Care Network Primary Care Physician Selection form.
- Fill out the form completely. The last section of the form, "Employer/Group use only" is for your employer to fill out. 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.
- Complete the form, sign and return it to us when you enroll in a new plan. If you are a Blue Care Network member, you will need to return the Blue Care Network Primary Care Physician Selection form along with this form.
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