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
2 digit month, 2 digit day, 4 digit 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 Michigan Medicine Registration at (734) 936-4990 to register or find your MRN.
Do you reside in Michigan?
*
Yes
No
Are you a University of Michigan Employee or Dependent?
*
Yes, I am a UM Employee
Yes, I am a spouse/dependent of a UM Employee
No, I am not affiliated with UM
Other
Did you receive a letter in the mail from UM benefits?
*
Yes
No
Select which of the following insurance plans you have:
*
BCN Premier Care
BCBSM Community Blue PPO (UM Plan)
Other
How did you hear about Rewind?
*
Recieved a letter in the mail from UM Benefits or Prime Therapeutics
Recommended by doctor, family, or friend
Online search/social media
Other
Is MI Eligible?
Yes
No
Submit
Should be Empty: