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Home  How To: Plans & Services: Member Download Forms
Member Download Forms
1. Please review the list of forms.
2. Select the form and an Adobe Acrobat .PDF file will open.
3. Complete the form and sign.
4. Return the completed and signed form to MEBS using one of the following methods:
› Fax to MEBS customer service at (616) 458-3495
› Scan the completed and signed form and email as an attachment to customerservice@mebs.com
› Mail to MEBS at 3809 Lake Eastbrook Blvd SE, Grand Rapids, MI 49546 For questions please call MEBS Member Services at (800) 968-6327.
HIPAA Forms (Individual Rights Forms)
MEBS Request for Access
MEBS Request for Confidential Communication
MEBS Request for Restriction
MEBS Request to Amend MEBS Authorization to Release Information
Claims Forms MEBS Payment Request Form
BCBSM Member Application for Payment Consideration
MEBS Letter of Medical Necessity Form
MEBS Debit Card Transaction Subst. Form
MEBS Flex/HRA Orthodontic Claim Form
MEBS Flex Dependent Care Receipt Form MEBS Authorization Agreement for Automatic Deposits (ACH)
For members who have enrolled in a MEBS STAR Plan, please use this claim form:
MEBS STAR Plan BCBSM Member Application for Payment Consideration
Disability
MEBS COBRA Notice and Procedure for Disability
MEBS COBRA Notice and Procedure for Other Coverage, Medicare or Cessation
MEBS COBRA Notice and Procedure for Second Qualifying Event MEBS Short Term Disability Claim Statement Form MEBS Disabled Dependent Enrollment Form
Member Enrollment And Change Forms
MEBS Member Enrollment and Change Form
AM Beneficiary Change Form
MEBS Section125 Mid-Year Benefit Change Request Form
MEBS mySource Card Enrollment Agreement Form MEBS Termination and COBRA Form MEBS Termination Form AM Optional Employee Benefits Form MEBS Section 125 Enrollment Form
MEBS HRA Enrollment Form MEBS Evidence of Insurability Form
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