State of Michigan retiree forms

What you’ll need to complete these forms:

  • Enrollee ID card
  • A prescription from your doctor
  • A copier or scanner to make copies of receipts for you to keep
  • A printer to print the form
  • An envelope and postage to mail the form

If you have any questions, call the number on the back of your enrollee ID card and we'll help.

Forms

You can continue health care coverage for your child older than age 19 with a developmental or physical disability, if your child meets the State’s criteria. To apply for continued coverage, fill out the State Health Plan Disabled Dependent Application (PDF).

You can request reimbursement if you had to pay an out-of-network doctor. You'll have to fill out a form to ask us to pay for medical, hearing or vision services.

  • If you’re insured with Blue Cross Blue Shield of Michigan and have the Medicare Supplemental PPO or New State Health Plan PPO, fill out a State of Michigan claim form.
  • If you have the BCN AdvantageSM Medicare Supplemental HMO, you can fill out the medical claim form listed under BCN Advantage.
  • If you don't have Medicare but have HMO coverage with the New State Health Plan HMO, fill out the Blue Care Network member reimbursement form