Blue Care Network Individual Member Change of Status Form

We want you to receive all the Blue Care Network benefits you are entitled to, so it is important to keep your records accurate.

If you're an individual health care plan member (you don't get your health insurance through an employer), use this form to tell us about:

  • Address changes
  • Name changes
  • Spouses or dependents who need to be added or removed
  • Coverage changes

If you have any questions, call the Customer Service number on the back of your enrollee ID card.

Access the form here: Blue Care Network Individual Member Change of Status form (PDF)

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form 
  • An envelope and postage to mail the form, or a fax machine.

Complete the form and return it to us within 30 days of the change. Then mail or fax the form to:

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

Fax: 1-877-218-1466

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