Benefits Forms: Claim Forms

IMPORTANT: All of the forms listed on these pages are in Adobe Portable Document Format (PDF). If you do not already have Adobe Acrobat Reader on your computer, you must download and install Adobe Acrobat Reader before you will be able to view or print Benefits forms.

Dental Plan Claim Form

• Delta Dental Claim Form

Flexible Spending Account Claims

• You may submit FSA claims online or by mailing in a paper form or sending a fax. Visit the FSA Claims page for instructions.

Medical Plan Claim Forms

• BCBSM Community Blue PPO Plan Claim Form (Domestic claims)
• BCBSM CMM Plan Claim Form (Domestic claims)
• BlueCard Worldwide International Claim Form (Foreign Claim)
• GradCare Member Reimbursement Form
  
  
• Health Alliance Plan (HAP) HMO
  As a general rule, HAP members should not receive bills from affiliated physicians for covered services received in network. However, HMO members should expect to receive bills for services received from out-of-network providers. If a member receives a bill that they feel should be HAP's responsibility, they should contact the HAP Client Services department for assistance or send a copy of the itemized bill, their HAP ID number, and receipts for payment to:
  
  HAP
  Claims Department
  2850 W. Grand Boulevard
  Detroit, MI 48202
  
  Members will receive an Explanation of Benefits (EOB) for claims processed that may include an out-of-pocket responsibility.
  
  
• Priority Health Claim Form
  
  
• U-M Premier Care Member Reimbursement Form
  

Prescription Drug Plan Claim Forms

• Prescription Drug Claim Form (informedRx/SXC)

Vision Plan Claim Form

• Davis Vision Direct Reimbursement Claim Form