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Forms and Resources

Coverage Information

Applications

Checklist for applying for Medicare Supplement Insurance.Use this checklist to assist you with the accuracy and completion of your enrollment application and the application process.

Medicare Supplement Application

Forms used with a new application

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage (Medicare Replacement Form). If you have a current Medicare Supplement or Medicare Advantage insurance and are replacing it with a Farm Bureau Health Plans of Michigan Medicare Supplement, please complete this form.

Claim Forms

Medicare Supplement Health Coverage Claim Form. Most providers will file health care claims for you. However, should you need to file a claim, please complete this form.

DentalVision Forms

Dental Bank Draft Authorization If you need to change your bank information for your DentalVision monthly premium payment, complete this form, attach a voided check and mail both to Farm Bureau Health Plans of Michigan.

Other Useful Forms

Questions or Complaints. This resource includes instructions on how to submit questions and complaints regarding your policy or coverage.

Notice of Privacy Practices.This notice explains your rights to privacy and how Farm Bureau Health Plans of Michigan may use your protected health care information.

Membership Application.Complete this form to apply for membership to the Michigan Farm Bureau. Membership is necessary to be eligible for coverage by Farm Bureau Health Plans of Michigan.

Bank Draft Authorization Form. If you need to change your bank information for your monthly premium payment, complete this form, attach a voided check and mail both to Farm Bureau Health Plans of Michigan.

Personal Representative Designation Form. Your completion of this form allows you to designate someone as your personal representative on your Farm Bureau Health Plans of Michigan coverage.

Medicare Supplement Plan Change Form (Upgrade). This form is for a change for an existing Farm Bureau Health Plans of Michigan Medicare Supplement in regards to plan upgrades.

Medicare Supplement Plan Change Form (Downgrade). This form is for a change for an existing Farm Bureau Health Plans of Michigan Medicare Supplement in regards to plan downgrades.

Cancellation Form. Please complete this form if cancelling your coverage with Farm Bureau Health Plans of Michigan.

Request for Reconsideration of Tobacco Rate. This form is for you to complete and submit if you have not used tobacco in over 24 months and would like to send a request to change to a non-tobacco rate.

This is where you can make your initial premium payment before your automatic payment plan starts. You can also make a payment here if your automatic payment didn’t process due to insufficient funds.

OneConnection Member Portal.This portal is for insured members to view benefit and claim information.

Medicare Supplements insured by Members Health Insurance Company, Columbia, Tennessee. Supplements not connected with or endorsed by the U.S. or state government or the Federal Medicare Program. This is a solicitation of Medicare Supplemental Insurance. This request for information is insurance-related and, if you respond, you may be contacted by a representative of Farm Bureau Health Plans of Michigan or Members Health Insurance Company regarding Medicare Supplement Insurance. Benefits are not provided for expenses incurred while coverage under the group policy/certificate is not in force, expenses payable by Medicare, non-Medicare eligible expenses or any Medicare deductible or copayment/coinsurance or other expenses not covered under the group policy/certificate.
MH-MI-WS-FL20-042