Member Information Change Form
Phone: 1-866-291-8691 Fax: 517-394-4590 Email: planmanagement@ihpmi.org
Today's Date:
*
/
Month
/
Day
Year
Date
Requesting Office Name:
Group #:
Staff person completing form:
Email
example@example.com
Phone:
MEMBER INFORMATION:
Name
First Name
Middle Initial
Last Name
Date of Birth:
/
Month
/
Day
Year
Date
HPMS #
Email:
example@example.com
MEMBER CHANGE/REQUEST:
Select an Option
Change Primary Care Provider Office: (must be a participating provider in the same CHP)
Deceased
Discharged from Office (attach discharge letter)
Member Address Change (member signature required)
Moved out of County
Order New Card
Other Medical Coverage
Pregnant
Other
Back
Next
Transfer from:
Office Name
Transfer to:
Office Name
Date of Death
-
Month
-
Day
Year
Date
Upload copy of Discharge Letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
Please enter a valid phone number.
Insurance Name:
Contract #:
Group #
Policy Effective Date:
/
Month
/
Day
Year
Date
Due Date
-
Month
-
Day
Year
Date
Back
Next
Member Signature: I verify that the above information is correct and authorize Health Plan Management Services on behalf of the Ingham Health Plan to update my records.
Clear
Date:
/
Month
/
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: