Appeal and claim forms
Evidence of Coverage
Non-opioid directive (Michigan)
Michigan has enacted a new law that allows people to refuse opioid medications by placing a non-opioid advance directive in their medical file. The goal of the new law – which went into effect 03/24/2022, is to prevent more people from becoming addicted to opioid pain medication.
Patients may revoke a non-opioid pain management form executed by themselves at any time and in any manner. A guardian or patient advocate may also revoke the form for a minor at any time and in any manner.
To add a non-opioid advance directive to your medical file, please fill out the form below and give it to your doctor.
Managing private informationAPC Authorization for Agent Access*
Request for Appointment of Personal Representative
Request for Confidential Communications and Restrictions
Request to Terminate Personal Representative - COMING SOON
Request to Terminate Confidential Communications and Restrictions
Authorization to Disclose Protected Health Information
Request for Accounting of Disclosures - COMING SOON
Request for Amendment of Private Information - COMING SOON
*Full medical access form available upon request
Out-of-network claim forms