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 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)