Member Handbooks and Forms

Member Handbook

The Member Handbook contains important information about your plans and acts as our contract with you. It explains:

• What’s covered
• What you pay
• Your rights and responsibilities

See below for the Member Handbook for your plan:

Certificate of Coverage

• Meridian Medicaid Certificate of Coverage (PDF)
• Meridian Healthy Michigan Plan Certificate of Coverage (PDF)

Member Forms

Appeal and Grievance Forms

• Appeal Authorized Representative Form (PDF)
• Grievance Authorized Representative Form (PDF)

Reimbursement Forms

• Gas Mileage Reimbursement Forms
  
  To use gas mileage reimbursement drivers need to register at least five business days prior to giving a ride. To register, visit the SafeRide website and add your driver information.
  • SafeRide Meridian Member Website
  • Gas Mileage Reimbursement Form (PDF)
  • Meals and Lodging Claim Form (PDF)

If you have questions about this change, pelase email us at meridian_driver@saferidehealth.com or call (800) 821-9369. 

Social Determinants of Health (SDoH) Assessment Form

This form will ask you questions about your health, lifestyle, and more. After you complete the assessment, we will connect you to a Community Health Worker, who can help you find local resources to address any challenges you’re facing.

• Social Determinants of Health (SDoH) Assessment Form (PDF)

Member Notification of Pregnancy Form

We have many ways to help you have a healthy pregnancy. Before we can help, we need to know you are pregnant. Contact Meridian as soon as you learn you are pregnant and our staff will help you submit a Notification of Pregnancy form (PDF). We will help set up special care that you and your baby need.

• Notification of Pregnancy Form (PDF)

This form can be submit via fax number 833-341-2052 or mailed to:

Meridian
PO Box 2010
Farmington, MO 63640-8080

Meridian wants to make sure that all birthing parents have access to high-quality care and resources for healthy and safe pregnancies and deliveries. In this booklet, you will find a list of benefits and services that can help you and your baby before, during, and after birth.

Maternity Benefits Booklet (PDF)

Protected Health Information Forms

• HIPAA Authorization Form (PDF)
• Authorization Revocation Form (PDF)
• Request For Access to Protected Health Info Form (PDF)
• Request For Confidential Communications Form (PDF)
• Restrictions To Protected Health Information Request Form (PDF)
• Request For Amendment of Protected Health Information Form (PDF)
• Accounting Of Disclosed Protected Health Information Request Form (PDF)