Upper Peninsula Health Plan

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Upper Peninsula Health Plan

UPPER PENINSULA HEALTH PLAN

PROVIDER FORMS

APPLICATION

Provider Application to the Upper Peninsula Health Plan  
(Revised August 2006.)

 

AUTHORIZATIONS
  • Clinical Services Prior-Authorization Request Form
         (Revised July 2007.)
  • DME/Medical Supply Request Form and Cover Sheet
         (Effective May 31, 2008.)
    		•
  • 4D Request for Prior Authorization Form
    		•
  • Synagis: 4D Request for Prior Authorization Form    
             (Effective September 2006.)
    		•

     

    DEPRESSION SCREENING
  • Edinburgh Postnatal Depression Scale (EPDS)
    		•
  • Patient Questionnaire PHQ-9

    •    Instructions—How To Score PHQ-9
  • Two-Question Screen Form
    		•
  • Two-Question Screen Labels
    		•

     

    UPDATES
  • Information Update Form
    		•
  • New Mental Health Provider Form (Facsimile)
    		•

     

    OTHER
  • Exception to Payment Form
    		•
  • No-Show Notification Form
    		•
  • Price-Negotiation Request Form
    		•
  • Vital-Sign Sheet
    		•

    Provider Relations

    Please contact our Webmaster with questions or comments about this site.
    © Copyright 1999 Upper Peninsula Health Plan, Inc. All rights reserved.

    Upper Peninsula Health Plan - 228 W. Washington Street - Marquette, MI 49855

    1-800-835-2556 or  906-225-7500

    Disclaimer