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Documents and Forms

Assign Your Care Decisions

Advance Directives

Advance Directives are legal records. They are used when you are very sick and cannot explain the kind of care you want. They let your family, friends and doctors know about your end-of-life choices ahead of time.

This document provides information about advanced directives such as a living will and durable power of attorney for health care.

Appointment of Representative Form (CMS-1696)

An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Use this form to appoint a representative to act on your behalf. Once you have completed and signed this form, please mail to the following address:

MeridianComplete
1 Campus Martius, Suite 700
Detroit, MI 48226

Greivance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday from 8 a.m. to 8 p.m.

Part D

To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY 711), Monday - Sunday from 8 a.m. to 8 p.m.

  • Member Request for Reimbursement (Prescription Medication) (PDF)
    Use this form to request reimbursement for a prescription/medication that you paid out of pocket for but believe should have been covered by the plan.

  • Medicare Grievance Form
    Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.

  • Part D Coverage Determination Request Form (PDF)
    Use this form to ask us to make a coverage determination and/or prior authorization. Once you have completed and signed this form, please mail to the address below.

    MeridianComplete
    Attn: Coverage Determination/Appeals
    1 Campus Martius, Suite 750
    Detroit, MI 48226

  • Part D Redetermination Request Form (PDF)
    If MeridianComplete denied your request for coverage of (or payment for) a prescription drug, use this form to ask us for a redetermination (appeal) of our decision. Once you have completed and signed this form, please mail to the address below.

    MeridianComplete
    Attn: Coverage Determination/Appeals
    1 Campus Martius, Suite 750
    Detroit, MI 48226
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