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Forms for Filing Financial Statements Introduction
The forms listed below are financial filing statements for: Health Maintenance Organizations/Alternative Financing and Delivery Systems/Nonprofit Health Care Corporations/Dental Service Corporations

For questions about the annual statements, quarterly statements, and Michigan supplemental forms, contact OFIS - Office of Financial Evaluation at (517) 241-4490 or toll free at (877) 999-6442.

Forms for Filing Financial Statements

• FIS 0084 PDF icon
Summary of Subsidiary Corporations

• FIS 0279 PDF icon
ANNUAL Notice of Medicaid Claims Defects (was quarterly)

• FIS 0317 PDF icon
Revenue and Expense Report for HMOs

• FIS 0318 PDF icon
Complaint and Grievance Summary for Health Carriers FIS 319 was merged into FIS 0318.

• FIS 0320 PDF icon
HMO Inpatient Discharges and Benefit Payouts Report

• FIS 0321 PDF icon
Working Capital Calculation for HMOs and AFDS

• FIS 0322 PDF icon
Michigan Health Insurance Enrollment, Premiums and Losses

• FIS 0323 PDF icon
Data Collection for 3515(3) Report

• FIS 0324 PDF icon
HMO Open Enrollment Disclosure
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