The Michigan Application for Reimbursement from the Medical Benefits Fund (fill-in form) is a document used by Michigan residents to apply for reimbursement from the state's Medical Benefits Fund. The form is used by individuals who have incurred medical expenses that are not covered by their health insurance, such as co-pays, deductibles, or other out-of-pocket costs. The form can be filled out online or printed and mailed to the Michigan Department of Health and Human Services. The form includes sections for the patient's personal information, the provider's name and address, and the expenses incurred. It also requires the patient to provide detailed information about the medical services received, including the diagnosis, the procedure, and the cost. Once the form is completed and submitted, the Michigan Department of Health and Human Services will review the application for reimbursement. There are two types of Michigan Application for Reimbursement from the Medical Benefits Fund (fill-in form): an individual application form and a family application form. The individual application form is for individuals who are seeking reimbursement for their own medical expenses. The family application form is for families who are seeking reimbursement for multiple family members' medical expenses.