MEDICARE ADVANTAGE BILLING CHANGE REQUEST

Use this form to change how you pay your premiums. If you’re looking to pay your premium bills, log in to MyBlue, and you will see a link to Pay My Bill on the homepage and within the “My Plan & Claims” menu.

Are you the Member or an Authorized Representative?

Please select one

Member

Authorized Representative

To the authorized representative who is assisting with the attestation:

You are attesting that you are authorized to act on behalf of the member. You also certify that:

1. You are authorized under state law to complete this attestation.

2. Documentation of this authority is available upon request by Blue Cross Blue Shield of Massachusetts or by Medicare.

Authorized Representative Information

Relationship to Member

Professional status or relationship, e.g. child, attorney, etc.

Relationship to Member - Other

First Name

Last Name

Email (optional)

Phone Number (optional)

e.g. (000) 000 - 0000

Street Address (optional)

Apartment or Unit Number (optional)

City (optional)

State (optional)

ZIP Code (optional)

e.g. 00000

Member Information

First Name

Last Name

Email (optional)

Phone Number (optional)

e.g. (000) 000 - 0000

Street Address

Apartment or Unit Number (optional)

City

State

ZIP Code

e.g. 00000

Member ID

Enter a three-character prefix, then numerical digits.

Plan Billing Change Request

Please select one

Premium Withhold

Direct Bill

Pay directly to the plan

I choose to pay my premium by automatically having it withdraw from one of the following options

Social Security (SSA)

Railroad Retirement Board (RRB)

You must continue to pay your plan premium until your Premium Withhold deductions begin.

Member Attestation

By submitting this attestation, I acknowledge that I have read and understand the contents of this declaration. To the best of my knowledge, the information on this attestation is true and correct.

Authorized Representative Attestation

By submitting this attestation, I, the authorized representative, acknowledge that I have read and understand the contents of this declaration. To the best of my knowledge, the information on this attestation is true and correct.

You may be contacted if additional information is needed.

All fields are required unless noted optional.

Contact Information

If you do have questions, call us at 1-800-200-4255 (TTY: 711).

April 1 - September 30
8:00 a.m. - 8:00 p.m. ET, Monday - Friday

October 1 - March 31
8:00 a.m. - 8:00 p.m. ET, seven days a week