Transportation Assistance Request Form
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.
- All reimbursement forms for mileage will be sent to the member.
- If your transport is arranged with a bus or cab company, the form will be sent to the member.
- If your transport is arranged with a volunteer driver, the form will go to the driver.

Please select which request you want to submit:  

Who is making the request?

Member Info
Member Last Name:
 Member First Name:
 Member ID:
Member Date of Birth:
 Home or Cell Phone Number:
Physical (Home) Address
Physical Street Address:
Physical City:
 Physical State:
 Physical Zip Code:



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


Member Profile Assessment


Appointment Info
Type of Visit:
 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.

Please agree to one of the following to continue



 
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.
MH_CS23TARForm H1977_001_CS23TARForm

Page Last Updated: December 29 2022