HealthChoice of Michigan Member Information Submission Form
In preparation for SGRX becoming the new Medical Provider effective 1/1/2026, we are seeking additional information from members to help ensure a smooth transition and continuity of care. Please feel free to contact our team at: 855.499.3232 if you have any questions or require any additional information, thank you!
Name
*
First Name
Last Name
Member ID
*
Group Number
Member Email Address
example@example.com
Member - Best Contact Phone Number
Please enter a valid phone number.
Primary Care Physician Update
Please identify the physician that should be designated as your primary care physician below. You can check to ensure the physician is in network using our search tool via the "Find a Doctor" button on the website.
Primary Care Physician
Primary Care Physician Phone Number
Please enter a valid phone number.
Referrals / Authorizations
If you require a referral or authorization for a future appointment, please direct your provider to our Providers page to fill out the required form for submission. https://connect.sgrxhealth.com/healthchoice/providers
Do you require a referral for an upcoming visit to a specialist? (after January 1, 2026)
*
Yes
No
Please provide the name of the specialist:
Do you require an authorization for an upcoming procedure or medication? (after January 1, 2026)
*
Yes
No
Please provide a brief description of the procedure and the date of the procedure or medication for which you require an authorization:
Are you currently prescribed any medications?
*
Yes
No
Please list the medications you are currently prescribed?
Please list the name of the prescription, strength and dosage.
What pharmacy do you use to fill your prescriptions?
Is there any additional information you would like to share with the SGRX team?
Submit
Should be Empty: