If you have a Blue Cross Blue Shield of Michigan plan other than Healthy Blue Achieve that requires a qualification form, please use the following form. Your doctor will submit the form by following the instructions on the back.
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.
What you’ll need
Your subscriber ID card, formerly known as enrollee ID
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.