Life Services Michigan Referral Form

If you would like to learn more about HAP CareSource Life Services, please fill out the form below. Note: You don’t have to enroll. You can reach us at <1-855-491-8350 (TTY: 711)> or by email at <MichiganLifeServices@CareSource.com>. We are open Monday through Friday, 8 a.m. to 5 p.m. We look forward to hearing from you!

Member First Name:

Member Last Name:

Member ID

Address:

City:

State:

ZIP:

County:

Phone:

Email:

Who is completing this form?

HAP CareSource Member Employer Community Organization

Name of Employer

Name of Community Organization

Name of person completing the form

Contact number of person completing the form

I would like to receive email from CareSource.
I would like a CareSource representative to call me.
I would like to receive information about CareSource Life Services through the mail.

I am interested in HAP CareSource Life Services for (please check all that apply): -- multi select checkboxes

Education Goal
Employment Goal
Linkage to Community Resources (For example: food assistance resources, transportation resources, housing resources, etc.)

This is NOT an Enrollment Application

MI-Multi-M-3279531 MDHHS Approved: 10/22/2024