Michigan BAC'

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Forms
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  • Assignment of Benefits Form

  • Blue Cross Blue Shield Enrollment Form

  • Request for Extension of Coverage for Adult Children under Age 26

  • Blue Cross Blue Shield Membership and Record Change Form

  • Change of Address Form

  • Loss of Time Statement

  • Subscriber Application for Payment (Instructions)

  • Subscriber Application Form

  • Direct Debit Authorization Agreement

  • Pension Deduction Authorization Form

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    6525 Centurion Drive, Lansing, MI 48917-9275
    Phone: 517.321.7502 • Toll-free: 800.531.2244 • Fax: 517.321.7508