Blue Cross Blue Shield Enrollment form 2022

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.

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Step by step instructions:
For Blue Cross Blue Shield of Michigan members
For Blue Care Network members

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:

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.
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:

For Blue Cross Blue Shield of Michigan members

Membership and Billing – M.C. 610G
Blue Cross Blue Shield of Michigan
P.O. Box 2260
Detroit, MI 48231-2260

Fax: 1-866-900-2619 or 1-866-900-2829

For Blue Care Network members

Membership and Billing – M.C. C411
Blue Care Network
P.O. Box 5043
Southfield, MI 48086

Fax: 1-877-218-1466

Small Businesses (1-100) | Large Groups (101+) | Cal-COBRA/COBRA

Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.

Get additional forms:

Additions, changes and deletions | Claims

Small Businesses (1-100)

Form	Purpose	Download/ complete online
Master Group Application (C15385)	This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application.	2022 Application Download PDF (English)1 (PDF, 751 KB) Download PDF (Spanish)1 (PDF, 677 KB)
Employee Application (C12914)	Employees should complete this application to enroll in a group medical plan, group vision plan, or group term life policy. Log in to Employer Connection to enroll a new or existing employee.	2022 Application Download PDF (English)1 (PDF, 1.5 MB) Download PDF (Spanish)1 (PDF, 1.6 MB)
Disability Addendum (C11248)	This form should accompany the new group application.	Download PDF (PDF, 431 KB)
HIPAA Release Form (A46163)	This is an authorization for the release of personal and health information.	Download PDF (PDF, 127 KB)
Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001)	This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan.	Download PDF (PDF, 117 KB)
Medicare Prescription Drug Plan Enrollment Form (PDP00045)	This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan.	Download PDF (PDF, 118 KB)

Large Groups (101+)

Form	Purpose	Download/ complete online
Master Group Application (C14939)	This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application.	2023 Application Download PDF (English) (PDF, 1.2 MB) Download PDF (Spanish) (PDF, 697 KB) Download PDF (Chinese) (PDF, 863 KB) Download PDF (Vietnamese) (PDF, 815 KB) Download PDF (Persian) (PDF, 853 KB)
Employee Application (C15390)	Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. Log in to Employer Connection to enroll a new or existing employee	Log in to complete the application online
Employee Application Medical only (C15390-H)	Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group.	Download PDF (English) (PDF, 1 MB) Download PDF (Spanish) (PDF, 1 MB) Download PDF (Chinese) (PDF, 1.1 MB) Download PDF (Vietnamese) (PDF, 1 MB) Download PDF (Persian) (PDF, 1.2 MB)
Employee Application Life only (C15390-L)	Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group.	Download PDF (English) (PDF, 814 KB) Download PDF (Spanish) (PDF, 814 KB) Download PDF (Chinese) (PDF, 944 KB) Download PDF (Vietnamese) (PDF, 836 KB) Download PDF (Persian) (PDF, 938 KB)
Employee Application Medical and life (C15390-HL)	Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. For employee enrollments to a new or existing employer group.	Download PDF (English) (PDF, 1 MB) Download PDF (Spanish) (PDF, 1 MB) Download PDF (Chinese) (PDF, 1.2 MB) Download PDF (Vietnamese) (PDF, 1 MB) Download PDF (Persian) (PDF, 1.2 MB)
Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001)	This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan.	Download PDF (PDF, 117 KB)
Medicare Prescription Drug Plan Enrollment Form (PDP00045)	This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan.	Download PDF (PDF, 118 KB)
Disability Addendum (C11248)	This form should accompany the new group application	Download PDF (PDF, 431 KB)
HIPAA Release Form (A46163)	This is an authorization for the release of personal and health information.	Download PDF (PDF, 127 KB)

Cal-COBRA/COBRA

Form	Purpose	Download/ complete online
COBRA Application (C11825-RTM)	If you are self administering or have a third party federal COBRA administrator and you have a qualified beneficiary electing to participate in COBRA, they must complete this application. Log in to Employer Connection to enroll a new or existing employee	Log in to complete the application online Download PDF (English) (PDF, 457 KB) Downlaod PDF (Spanish) (PDF, 91 KB) Download PDF (Chinese) (PDF, 161 KB) Download PDF (Vietnamese) (PDF, 178 KB)
Employer Notification of Qualifying Events Under Cal-COBRA (C13140)	Complete this form when covered employees have an event that qualifies them for coverage under the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719).	Download PDF (PDF, 134 KB)
Cal-COBRA Take-Over Form (C14755)	New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required fill out the form and submit to the Cal-COBRA team within 30 days of transition.	Download PDF (PDF, 75 KB)
Continuing Group Coverage after FederalCOBRA Cal-COBRA Election Form (C52299)	After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible for an 18-month extension through Cal-COBRA. Beneficiary must contact Cal-COBRA (800-228-9476 ) to request the extension and ensure they meet the requirements. If approved, the beneficiary will submit this form to formally accept the extension.	Download PDF (PDF, 1.5 MB)
Cal-COBRA Election Form (C13141)	Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140).	Download PDF (PDF, 113 KB)
Cal-COBRA Dental Election Form (C18156)	For dental only groups: Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140).	Download PDF (PDF, 71 KB)

1Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.

W-9s and other IRS forms

Blue Shield of California plans: Download W-9 (PDF, 38 KB)

Blue Shield of California Life & Health Insurance Company plans: Download W-9 (PDF, 38 KB)

Not sure which form to use? Give us a call at (800) 325-5166.

We update these forms often, but still advise that you check the IRS website to make sure you have the most recent W-9s. You can also find the tax forms you need.