Transportation Reimbursement Request

Upper Peninsula Health Plan

Phone: 1-800-835-2556

Individual Transportation Reimbursement Request Form

To submit a Transportation Reimbursement Request for Upper Peninsula Health Plan, please provide the following information:

Please select which request you want to submit:

Your Name:

Member Last Name:
Member First Name:
Member ID:
Physical Street Address:
Zip Code:
P.O. Box (if applicable):
Home Phone Number:
() -
Appointment Date: (MM/DD/YYYY)
Appointment Time: (hh:mm AM/PM)
Additional Appointment Dates:
(list additional dates if appointment is scheduled on a regular basis at the same time (ie. Physical Therapy, Dialysis))
Provider Last Name:
Provider First Name:
Provider Phone Number:
() -
Type of Visit:
Description of Visit:
Appointment Location Address:
Appointment City:
Appointment State:
Appointment Zip Code:

Page Last Updated: 2/28/2017