Mercy Health 20% Discount
This form is to help the Union follow up with bargaining unit members who have had issues obtaining the 20% discount on eligible Mercy Health goods and services, or issues obtaining a reimbursement for a denial of the discount.

Please fill out all the information you have so that we can follow up!

Last name: *
Your answer
First name: *
Your answer
Phone number
Your answer
Email Address
Your answer
Bargaining Unit? *
Who received the service or good? (self or dependent, if dependent, please state their name) *
Your answer
Was the discount applied at the point of service/sale? *
If no, who denied you the discount?
Your answer
If no, what were you told?
Your answer
If no, when did this occur? where?
Your answer
Were you given the discount at the point of sale and then later billed for the amount of the discount?
Have you submitted a claim to HR4U? If yes, include the date you filed the claim
MM
/
DD
/
YYYY
Do you have (did you submit) all the documentation you need to file claim? If you'd like further assistance, please send your documents to nanette.homan@seiuhealthcaremi.org
Any other information you want to tell us?
Your answer
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This form was created inside of SEIU Healthcare Michigan.