Member Information Change Form
Phone: 1-866-291-8691 Fax: 517-394-4590 Email: planmanagement@ihpmi.org
Today's Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MEMBER INFORMATION:
Name
*
First Name
Middle Initial
Last Name
Date of Birth:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
HPMS #
MEMBER CHANGE/REQUEST:
Select an Option
*
Change Primary Care Provider Office: (must be an
IHP participating provider)
Member Address, Phone or Email Change
Moved out of County
Order New Card
Other Medical (Health) Coverage
Pregnant
Other
Back
Next
Transfer from:
Office Name
Transfer to:
Office Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Insurance Name:
Contract #:
Group #
Policy Effective Date:
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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.
Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*
Submit
Should be Empty: