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.


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

(Effective May 2016.)

(Effective December 2016.)

(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.)

CMS Medicare DME Fee Schedule 

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.)


Care-Coordination/Case-Management Referral Form

Newborn Notification Form

Newborn Notification Form (fillable version)

Notification of Pregnant Member
(Revised September 2014.)

Price-Negotiation Request Form
(Revised September 2016.)


Adobe Acrobat Reader

American Academy of Family Physicians
Family Practice Management Toolbox

American Diabetes Association
Risk Test

Baby and Pregnancy Tips

Chickenpox Information

Children’s Special Health Care Services

Coordinating Medicaid Benefits
Coordinating Medicaid benefits with commercial insurance
Michigan Department of Health and Human Services

Epocrates® Pharmacy Reference

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 Action Coalition

Immunization Handouts and Resources

Influenza in Michigan
Michigan Department of Community Health

Lead Poisoning Information

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 Kids!

Michigan Medicaid Fee Schedules
Michigan Department of Health and Human Services

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