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Home  Our Valued Members Create Account: Forms for Members
Forms for Members
Please select a form and the Adobe Acrobat .PDF file will open. Then complete the form online by clicking in the form boxes and once completed, print, sign, and mail or fax to MEBS customer service at 616-458-3495.
Or,
select a form, print it and complete by hand, sign and mail or fax to us.
HIPAA Forms
Individual Rights Forms
Request for Access
Request for Confidential Communication
Request for Restriction
Request to Amend
Authorization to Release Information
HIPAA Plan Sponsor Certification Form
Claim Forms
MEBS Payment Request Form
BCBSM Member Application for Payment Consideration
Letter of Medical Necessity Form
MEBS Debit Card Transaction Subst. Form
For members who have enrolled in a MEBS STAR Plan,
please use this claim form:
MEBS STAR Plan BCBSM Member Application for Payment Consideration
COBRA Forms
Notice and Procedure for Disability
Notice and Procedure for Other Coverage, Medicare or Cessation
Notice and Procedure for Second Qualifying Event
Termination and COBRA Enrollment Form
Claims Reimbursement Forms
Orthodontic Claim Form
MEBS Flex Dependent Care Receipt Form
Disability Forms
Short Term Disability Claim Statement Form
Miscellaneous Forms
Beneficiary Change Form
Employee Change of Status Form
COB - Coordination of Benefits Questionnaire
Medicare Part D Creditable Notice Letters
Model Notice Ready for Employer Customization
Model Notice MEBS Medicare Part D
Member Enrollment and Change Form 
MEBS Member Enrollment and Change Form
Optional Benefit Enrollment Form
MEBS Optional Enrollment and Change Form
MEBS Section 125 Enrollment Form
MEBS Evidence of Insurability Form
Links to Other Forms:
Forms for Employers
MEBS Retirement Services Forms
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