Michigan Rewind Enrollment Form
Please complete this quick form to confirm your Michigan Medicine/Rewind program eligibility. A scheduling representative will follow up with you to schedule your intake appointment.
What is your first and last name?
*
First Name
Last Name
What is your date of birth?
*
-
Month
-
Day
Year
Date
What is your email?
*
example@example.com
What is your cellphone number?
*
What is your UM Medical Record Number (MRN)?
If you do not yet have a MRN, or can't find yours, that's ok. Go ahead and complete this form to start the process, and then we recommend calling the U-M Patient Portal Help Desk at (734) 615-0872 to register or find your MRN.
Do you reside in Michigan?
*
Yes
No
How did you hear about Rewind?
*
I'm a UM Employee (or Spouse, Dependent, or Retired)
Other
Did you receive a letter in the mail from UM benefits?
Yes
No
Select which of the following insurance plans you have:
Blue Cross Blue Shield - Michigan (Community Blue PPO)
Blue Care Network (GradCare, PremierCare, CDHP, CMM)
Other
Do any of the following apply to you? Please select all that apply, or select None.
*
T2D with major complications such as moderate to severe proliferative retinopathy or kidney disease (stage 4 or beyond)
Pregnant/breastfeeding (or planning to be while in the program)
Prior bariatric weight loss surgery
Type 1 diabetes
Active cancer (other than minor skin cancers)
AIDS
Current nicotine use (or recent changes in smoking habits within last 6 months)
Substance abuse use disorder or sobriety
Psychiatric disorder such as schizophrenia or bipolar disorder
Diagnosed eating disorder such as bulimia or anorexia nervosa
None
Is MI Eligible?
Yes
No
Submit
Should be Empty: