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Please choose the type of form you need from the following list.
The Summary of Benefits, Evidence of Coverage and Annual Notice of Changes documents included above are for HAP individual Medicare plan members only. If you receive coverage through a group or employer, please contact us for more information.
Flexible Health Options Form (PDF) (for HAP Senior Plus members only) – submit a form for review and consideration of benefit payment
Appointment of Representative Form (PDF) – appoint a doctor, lawyer or family member to request a coverage determination or file an appeal or grievance on your behalf
Know Your Medical Rights (Advanced Directive PDF) – understand your right to appoint a representative to act on your behalf
Authorization for HAP to Release Personal and Health Information (PDF) – give HAP permission to release personal health information to those you approve
Provider Waiver of Liability (PDF) (for HAP Senior Plus members only) – a noncontract physician or other noncontract provider who has furnished a service to the enrollee can formally agree to waive any right to payment from the enrollee for that service
Admission Team Authorization Request - a health care provider is requesting an in-patient admission
Referral Management Team Authorization Request Form - a heath care provider is requesting a prior authorization
Behavioral Health Service Request Form - a health care provider is requesting a prior authorization for behavioral health services
Authorization for Automatic Withdrawal (PDF) - give HAP permission for automatic withdrawals
Copyright © 2017 HAP
2017 Health Alliance Plan of Michigan
Y0076_ALL_2018029 Website MP
CMS Approved: 6/26/2017
Last Update: 6/21/2017
HAP Senior Plus HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.
This information is not a complete description of benefits. Contact the plan for more information. Limitation, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and or provider network may change at any time. You will receive notice when necessary.
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