Subscriber New Enrollment Form

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. 

Step by step instructions:

1. On the top of the form, choose what type of health insurance provider you'd like to enroll with by checking the box for either Blue Cross Blue Shield of Michigan or Blue Care Network. If you are a Blue Care Network member, you'll need to return the Blue Care Network Primary Care Physician Selection form along with this form.
2. 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 or faxing it to us.

Fax or mail the form to:

 

 

 

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• Blue Care Network primary care physician form
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• How can I choose or change my primary care physician online?