Forms

To help you support your Upper Peninsula Health Plan members, you can download and print the forms and documents found below.  If you cannot find the form you are looking for, contact Customer Service at 1-877-349-9324 for assistance.

Appointment of Representative Form

Care Coordination/Case Management Referral Form
Print Only

Care Coordination/Case Management Referral Form
Fillable Version

UPHP Advantage Coverage Determination Request Form

UPHP MI Health Link Coverage Determination Request Form

DME/Medical Supply Prior Authorization Request Form
(Effective October 2015.)

Prior-Authorization Request Form
Print Only
(Revised April 2017.)

Prior-Authorization Request Form
Fillable Version
(Revised April 2017.)

H2161_H1977_2017_WP0001v5, Pending
Page Last Updated: 05/30/2017