Rewind Health History Form

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 NameLast Name
What is your date of birth? *

MonthDayYear
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 Michigan Medicine Registration at (734) 936-4990 to register or find your MRN.
Do you reside in Michigan?*

YesNo
How did you hear about Rewind?*

I'm a UM Employee and received a letter in the mail from UM benefits or Prime TherapeuticsI'm a UM Employee but did NOT receive a letter in the mail from UM benefits or Prime TherapeuticsOther
Did you receive a letter in the mail from UM benefits?*

YesNo
Select which of the following insurance plans you have:*

Blue Cross Blue Shield - Michigan (Community Blue PPO)Blue Care Network (GradCare, PremierCare, CDHP, CMM)MichiganCare (University of Michigan Health Plan)Medicare AdvantageMedicaidOther
Do any of the following apply to you? Please select all that apply, or select None.*

Type 2 diabetes with complications such as moderate/severe eye disease, chronic kidney disease (stage 4 or beyond)Pregnant or trying to conceiveCurrent breastfeedingType 1 diabetesPrior bariatric weight loss surgeryActive cancer (other than minor skin cancers)AIDSCurrent nicotine use (or recent changes in smoking habits within last 6 months)Substance use disorder and/or abstinence < 1 yearPsychiatric disorder such as schizophrenia, bipolar disorderDiagnosed eating disorder such as bulimia or anorexia nervosaNone
Is MI Eligible?

YesNo
Should be Empty:

Michigan Rewind Enrollment Form