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Office of the General Counsel Subrogation Department 232 S. Capitol Ave. L09A Lansing Michigan 48933-1504 517 325-4658 FAX No. 877 257-2012 E-mail SubrogationUnit bcbsm.com BCBSM SUBROGATION QUESTIONNAIRE FAX COMPLETED FORM TO 877-257-2012 or MAIL TO ADDRESS ABOVE Date Patient Name Date of Birth Contract 9 digit number on BCBSM card Spouse if on BCBSM policy BCBSM policy holder s name if different from the patient s name Your phone number Type of.

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