Get Mi Wf 10339 2010-2025

Filling out the MI WF 10339 form is essential for the coordination of benefits with Blue Cross Blue Shield of Michigan. This guide will provide you with a clear and step-by-step approach to ensure the form is completed accurately and efficiently.

Follow the steps to complete your MI WF 10339 form online

1. Click ‘Get Form’ button to obtain the MI WF 10339 and open it for completion.
2. In Section 1, provide your BCBSM enrollee information, including your name as it appears on your ID card and your enrollee ID or contract number. Indicate whether you or your covered dependents have additional group health coverage, selecting 'NO' to skip to the end of the form or 'YES' to complete the rest.
3. In Section 2, enter details about the policy holder of any other health coverage, including their name, relationship to you, social security number, employer, and birth date. Fill in the insurance company name and address, along with the enrollee ID, policy number, and group number.
4. Indicate the type of coverage — either single or family — and whether it is a retiree contract, COBRA contract, or if the policy holder is laid off. Check the appropriate boxes.
5. List who is covered by the other plan, ensuring to include yourself if applicable. Provide the names and relationships of each covered individual.
6. Complete Section 3 if applicable, detailing health care coverage for your children resulting from divorce or separation. Note if there are court orders determining health care coverage responsibility and provide details as required.
7. Sign the form at the designated area, and include the date of completion.
8. Return the completed form either by mailing it to Blue Cross Blue Shield of Michigan at the provided address or faxing it as indicated.

Start completing your MI WF 10339 form online today for convenient management of your benefits.