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Please choose the type of form you need from the following list.
2018 HAP Medicare Plans
2018 HAP Medicare plans
2018 HAP Medicare plans
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.
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
Authorization for Automatic Withdrawal (PDF) - give HAP permission for automatic withdrawals
Copyright © 2018 HAP
2018 Health Alliance Plan of Michigan
Y0076_2019 HAP Website
CMS Accepted 10/1/2018
HAP Senior Plus (HMO)/(HMO-POS)/(PPO) and HAP Primary Choice Medicare (HMO) are health plans with Medicare contracts. HAP Empowered Duals (HMO SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment in the plans depends on contract renewals. HAP Senior Plus (PPO) 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. For more information call Medicare Michigan customer service at (800) 868-9885 (TTY: 711) 8 a.m. to 8 p.m., seven days a week (Oct. 1 – March 31) / 8 a.m. to 8 p.m., Monday through Friday (April 1 - Sept. 30).
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