Fill out (online or by hand), print,
sign and mail this form with original receipts to:
Blue Cross Blue Shield of Michigan
Medicare Plus Blue PPO
Imaging and Support Services
P.O. Box 32593
Detroit, MI 48232-0593
Patient's Enrollee ID
The enrollee or member ID can be found on your Blue Cross ID card
Alpha
Numeric Group number
Medicare Plus Blue PPO
Member information
Patient's last name Patient's first name
Patient's street address
City
State ZIP code
Patient's date of birth
Sex
M
F
To speed up processing of your request, please remember to:
• Complete one form for each enrollee.
• Mail only original clear it
emized bill(s) that include(s) the following:
- Your flu shot provider's logo, address, and phone number (for example - from a doctor, pharmacy,
community center, or local health department)
- Date of service
- Amount paid
- Vaccine name or description
• Keep copies of your original receipts for your files. We can’t return originals to you.
I certify the above information is true, the enclosed material is correct and unaltered, and the expenses
were incurred by the enrollee listed
above. False receipts or altering of this information will result in civil
or criminal prosecution. I authorize the release of any information as described below.
Enrollee’s signature Date Phone
WF 17375 SEP 18
Medicare Plus Blue and BCN Advantage are PPO, HMO-POS and HMO plans with Medicare contracts.
Enrollment in Medicare Plus Blue and BCN Advantage depends on contract renewal.
Y0074_IGFluPneumoReimbFrm_C FVNR 0918
We value your privacy. We won't release any information about you unless you ask us to in writing or we
must do so to process or review your claim (sharing with another insurance company, for example).
We'll tell you which information we released and to whom, if you request it.
SM
Member Flu and Pneumonia Shot
Reimbursement Form
Blue C
Blue Shield
a Blue Ca Nrk
Medicare Plus Blue PPO, BCN Advantage HMO-POS
and BCN Advantage HMO
SM
SM SM
BCN Advantage HMO-POS
SM
SM
BCN Advantage HMO
SM
SM
Blue Care Network
BCN Advantage HMO
Member Reimbursements – G804
P.O. Box 68753
Grand Rapids, MI 49516-8753
