Appeal and claim forms
Evidence of Coverage
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
National ancillary list
Ascension Personalized Care offers a network of national ancillary providers to ensure convenient access to high quality, cost-effective services, including but not limited to medical supplies, durable medical equipment (DME) and other services. In addition to these national vendors, locally based participating doctors may be available. Please check the Ascension Personalized Care provider directory to find a local doctor.
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.
Out-of-network claim forms
Schedule of Benefits