For your convenience, we’ve included all of the forms and search functions here in one place. (Documents are easy to access and print, too.) If you have any questions, please don’t hesitate to call us at the number below. As the only doctor-built, patient-focused plan in Michigan, you are our top priority. We are ready and waiting to help in any way we can.
Documents and Forms for Members
Reliance Medicare Advantage (HMO and HMO-SNP) Information
Confidential and Representative Forms and Policies Appointing a Representative You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
Here are CMS model Redetermination and Coverage Determination Request forms developed specifically for use by all Part D prescribing physicians or enrollees. You may use the Model Part D Redetermination Request forms or the Coverage Determination forms. Both of these forms will be accepted.
October 1 - March 31: Seven days a week from 8:00 a.m. - 8:00 p.m. Eastern. April 1- September 30: Monday through Friday from 8:00 a.m. - 8:00 p.m. Eastern.
If you know someone else looking for a better Medicare Advantage value, please have them contact us directly.
Doctor-Built, Patient-Focused.
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Member portal is going through an upgrade and is currently not working. It will be operational on March 22.
