Forms and Links
Provider Forms
Provider Network Participation and Application
Please contact the Provider Relations Department if you would like to discuss contracting and credentialing with Upper Peninsula Health Plan (UPHP) or if you would like to discuss changes to your participation. You may contact them at 906-226-4285 or send an email to Provider Relations.
Authorizations
Pharmacy Prior-Authorization Form
(Print Only) Effective January 2015.
Pharmacy Prior-Authorization Form
(Fillable) Effective January 2015.
Medical Needs Form– Fax completed form to UPHP
(Revised October 2008.)
Diplomat Specialty Pharmacy Form
J-Code Prior-Authorization Form
(Print Only) Effective May 2016.
J-Code Prior-Authorization Form
(Fillable) Effective May 2016.
Prior-Authorization Request Form
(Revised April 2017.)
Prior-Authorization Request Form (fillable version)
(Revised April 2017.)
UPHP Home Health Care Prior Authorization Form
UPHP Home Health Care Prior Authorization Form (fillable version)
Michigan Prior Authorization Request Form
J-Code Pharmacy Bulletins
Botox
(Effective May 2016.)
Remicade
(Effective December 2016.)
Nucala
(Effective April 2017.)
Durable Medical Equipment
DME/Medical Supply Prior Authorization Request Form
(Revised March 2017.)
DME/Medical Supply Prior Authorization Request Form
(Revised March 2017. Fillable Version.)
DME/Medical Supply Prior Authorization Request Form Guide
(Effective October 2015.)
MDHHS Medicaid DME Fee Schedule
MDHHS MIChild DME Fee Schedule
Provider Manual
This contains the health plan’s benefits, policies, and instructions on how to utilize our services.
Healthy Michigan Plan
Healthy Michigan Plan Health Risk Assessment
Healthy Michigan Plan Brochure
MDHHS Healthy Michigan Plan Copay Information Sheet
Release of Protected Health Information form
Provider Information Updates and Changes
Information Update Form
(Revised March 31, 2017)
New Community Mental Health Provider Form (facsimile)
(Revised July 2016)
Provider to Provider Discussion – Pain Management
(Effective June 21, 2016.)
Other
Care-Coordination/Case-Management Referral Form
Newborn Notification Form (fillable version)
Notification of Pregnant Member
(Revised September 2014.)
Price-Negotiation Request Form
(Revised September 2016.)
Links
American Academy of Family Physicians
Family Practice Management Toolbox
American Diabetes Association
Risk Test
Children’s Special Health Care Services
Coordinating Medicaid Benefits
Coordinating Medicaid benefits with commercial insurance
Michigan Department of Health and Human Services
Family-to-Family Health Information and Education Center
The Michigan Family-to-Family Health Information and Education Center aims to improve access to high-quality care and supports for children with special needs by empowering families.
Healthy Kids Dental
A program to improve access to dental care for underserved children
HMO Consumer Guide
Michigan Office of Financial and Insurance Services Health Maintenance Organization (HMO) Consumer Guide
Immunization Handouts and Resources
Influenza in Michigan
Michigan Department of Community Health
Medicaid Provider Manual
Michigan Department of Health and Human Services
Michigan Association of Health Plans (MAHP)
The MAHP facilitates communication among members, government, and the industry regarding health care issues of common concern
Michigan Department of Human Services (MDHHS)
Michigan Medicaid Fee Schedules
Michigan Department of Health and Human Services
MIChild
A health-insurance program for the uninsured children of Michigan’s working families
Physician Group Incentive Program
Blue Cross Blue Shield of Michigan
Tobacco Dependence in Michigan
Provider training module for effective cessation interventions and systems
United States Consumer Product Safety Commission
Recalls and product safety news
Upper Michigan Memory Loss Information and Help
Upper Peninsula Diabetes Outreach Network (UPDON)
Upper Peninsula Health Care Network (UPHCN)
The Upper Peninsula Health Care Network is a regional, integrated, information-systems network to connect the Upper Peninsula hospitals, providing a cost-effective mechanism to access patient information and to streamline patient-care delivery.
Upper Peninsula Health Group (UPHG)
The Upper Peninsula Health Group administers progressive health care solutions to employers and other purchasers of health care services.
Page Last Updated: 06/5/2017