Forms for Providers

Included on this page are Change and Enrollment forms as well as Michigan Department of Health and Human Services forms. These forms help providers participate with Blue Cross Complete of Michigan as well as the state of Michigan.

Helpful forms

Enrollment forms

Are you interested in participating with Blue Cross Complete of Michigan? If so, complete the appropriate form below:

More information on enrollment requirements can be found in the Medicaid Provider Enrollment Requirements (PDF).

Federal Qualified Health Centers should follow the FQHC credentialing guidelines (PDF).

Change forms

If you are already enrolled but need to change things such as provider name, contact information, office hours, panel status, or hospital affiliations, please fill out the Provider Change Form (PDF).

Where to submit forms

Submit forms using one of the following contact methods:

 

Blue Cross Complete of Michigan
Attention: Provider Network Operations
4000 Town Center, Suite 1300
Southfield, MI 48075

 

Email: bccproviderdata
Fax: 1-855-306-9762

Health Risk Assessment

Use the Health Risk Assessment form to assess a patient’s healthy behaviors. This form is required for Healthy Michigan Plan beneficiaries. 

Prenatal and infant forms

Use these forms to communicate patient prenatal and infant information to the health plan.

Blood lead test forms

Blood Lead Test Requisition form DCH-0696 (PDF)
Use this form to submit blood specimens for blood lead testing to the Michigan Department of Health and Human Services.

Blood Lead Results Reporting form MSA-1532
Use this form to report additional blood lead results, not previously reported to the Michigan Department of Health and Human Services.

Other MDHHS forms

Acknowledgement of Receipt of Hysterectomy Information (PDF)
Use this form to confirm that a patient has received and understands hysterectomy information prior to a procedure.

Beneficiary Verification of Coverage MSA – 1550 (PDF)
Use this form to confirm that a patient understands payment coverage for an elective abortion under limited circumstances.

Consent for Sterilization (PDF)
Use this form to confirm that a patient understands and consent to sterilization.

Certification for Induced Abortion (PDF)
Use this form to certify that a patient understands that their life would be endangered if the pregnancy were continued or cases in which the pregnancy was the result of rape or incest.

Clinical Specimen Shipping Units Requisition form DCH-0568 (PDF)
Use this form to ship clinical specimens to the Michigan Department of Health and Human Services.

 

Michigan Department of Health & Human Services
333 S. Grand Ave
P.O. Box 30195
Lansing, Michigan 48909