BCN

Member Reimbursement Form

Blue Care Network of Michigan

I paid out of pocket and am requesting reimbursement for medical services.

Your email address

We'll send you a confirmation when the form is submitted and again when BCN confirms receipt of the fax.

1Member Information

Enrollee ID (on your member ID card)

Enrollee Name

Patient Name

Patient Date of Birth

Address

City

State / ZIP Code

Description / explanation of claim

Include: provider name, phone, tax ID, NPI, diagnosis code, procedure code, date(s) of service, amount charged, and proof of payment.

The above statements and attachments are true and complete to the best of my knowledge.

Signature (draw below, then click Save)

Date

Fax to: 1-866-637-4972

Or mail to:

Member Reimbursements - G802

Blue Care Network

P.O. Box 68767

Grand Rapids, MI 49516-8767

Questions? Call Customer Service

1-800-662-6667

1-800-257-9980 (TTY users)

8 a.m. to 5:30 p.m. Monday – Friday

Please keep a copy of all documents you send us. Allow 30 days for processing.

This saves your submission to the database. Use "Download PDF" in the preview to get the printable form.

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