UPHP - Transportation Assistance Request

	TRANSPORTATION ASSISTANCE REQUEST
For urgent requests, please contact the UPHP Transportation Department at 1-800-835-2556 (TTY: 711), Monday through Friday from 8 a.m. to 5 p.m. Eastern Time. The call is free.
The Upper Peninsula Health Plan (UPHP) provides non-emergent, medical transportation (NEMT) to medically necessary, covered services for UPHP members. UPHP provides NEMT via mileage reimbursement or transportation. Mileage reimbursement is available for members who have a vehicle, or a friend, family member or neighbor willing to transport them. Transportation is available for members who do not have a vehicle or someone to transport them. Follow the instructions below to request reimbursement or transportation. If you have any questions, please call the UPHP Transportation Department at 1-800-835-2556.

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Mileage reimbursement is available for members who have a vehicle, or a friend, family member or neighbor willing to transport them.
Complete the UPHP Mileage Reimbursement Request in its entirety, no later than 90 days from your appointment to receive reimbursement for UPHP covered appointments and services.
You must attach your completed mileage reimbursement request, signed by the provider(s) or attach proof of the appointment, such as a letter from the office or a discharge summary.
If your appointment was over 400 miles round trip, attach any meal or lodging receipts.
If a friend, family member, or neighbor transported you to the visit, ensure they have filled out the NEMT Attestation. They only need to submit this one time. Please attach with your proof of the appointment for them to receive reimbursement.

Who is making the request?
I am requesting for myself (I am a UPHP member)
I am requesting on behalf of a UPHP member

Representative Last Name

Representative First Name

Representative Phone

Relationship to Member

Member Info

Member Last Name:	Member First Name:	Member ID:
Member Date of Birth:	Home or Cell Phone Number:

Member Physical (Home) Address

Member Physical Street Address:
Member Physical City:		Member Physical State:	Member Physical Zip Code:

Mailing Address is the same as Physical Address

Member Mailing Address

Member Mailing Street or PO Box:
Member Mailing City:		Member Mailing State:	Member Mailing Zip Code:

I only need reimbursement for attached receipts such as bridge tolls, parking, meals or lodging.

Member Profile Assessment

Have you used UPHP transportation in the last 6 months?

I am a UPHP member and I drove myself to my appointment(s)

Driver Info

Driver Last Name:	Driver First Name:	Driver Date of Birth:
Driver Relation to Member?	Driver Home or Cell Phone Number:

Driver Mailing Address

Driver Mailing Street or PO Box:
Driver Mailing City:		Driver Mailing State:	Driver Mailing Zip Code:

Appointment Info

Appointment Type:	Provider Last Name:	Provider First Name:	Provider Phone Number:
Appointment Location Address:
Appointment City:		Appointment State:	Appointment Zip Code:

Appointment Dates (add up to 30 dates)

Please submit a separate request form for each provider and visit type.

Attachments (Signed Proof of the Appointment, Doctor's Note or NEMT Attestation)

Please agree to one of the following to continue

I have read and agree to the UPHP Transportation Rules & Regulations
Please mail me a hard copy of the UPHP Transportation Rules & Regulations

Upper Peninsula Health Plan (UPHP) MI Health Link (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.
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Page Last Updated: July 28 2023