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  • Healthy Blue Living Bcn Qualification Form (pdf)

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Member instructions for qualification form Fill out the member section on the reverse side of this form and take it to your physician for completion. Your doctor must electronically submit the form.

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Certificate of Creditable Coverage A written certificate issued by a group health plan or health insurance issuer (including an HMO) that shows your prior health coverage (creditable coverage).

You will receive Form 1095-A, Health Insurance Marketplace Statement, which provides you with information about your health care coverage. You should wait to file your income tax return until you receive that form.

In Michigan, qualified health coverage is the insurance that the No-Fault insurance law requires drivers to have to be able to select certain PIP medical benefit levels. To ensure your health plan meets the requirements of the law, it must not exclude or limit coverage for car accident-related medical care.

There are several ways you can request a QHC letter. You can log in to your online member account to see if you have a QHC letter to download. Once logged in, navigate to the QHC letter in the Proof of Insurance section at the bottom of the page. You can call the number on the back of your member ID card.

Submit a copy of one of the following documents. Certificate of coverage or letter from the health plan issuer showing the end date of coverage. Government-issued document showing date of termination of coverage or ineligibility to program.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232