Member Information

Member First Name:

Member Last Name:

Member Date of Birth:

Member ID:

Member Mailing Address 1:

Member Mailing Address 2:

Member Mailing City:

Member Mailing State:

Member Mailing Zip Code:

Member's Health Plan:
The member is enrolled in UPHP Medicaid, Healthy Michigan Plan (HMP) or Children's Special Health Care Services (CSHCS)
The member is enrolled in UPHP MI Health Link (MHL) or MI Coordinated Health (MICH)

Submitter Information

Who is submitting this form?
I am a UPHP Member
I am a UPHP Member's Authorized Representative or Legal Guardian
I am a Provider UPHP members can have a relative, friend, attorney (lawyer), doctor or someone else act as their representative. The member (or their legal guardian) and the person they want to act for them must sign and date a form saying this is what they want. If we do not get the information we need, such as a signed request or proof of guardianship, the appeal may be dismissed. Appointment of Representative Form

Submitter First Name:

Submitter Last Name:

Call Back Number:

Call Back Extension:

Submitter Mailing Address 1:

Submitter Mailing Address 2:

Submitter Mailing City:

Submitter Mailing State:

Submitter Mailing Zip Code:

Fax Number:

Email Address:

Submission Details

Did someone from UPHP ask you to submit this request? YES NO

Please enter their name:

First Name

Last Name/Initial

Reason for Submission:

Attach Documents

Please attach documents you have to support the request. Some examples are medical records, prescriptions, orders, test results, receipts, or letters.