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Forms and Links

Pharmacy Authorizations
  • Prescription Prior Authorization/Medicaid
  • Diplomat Specialty Pharmacy
  • Medical Pharmacy Prior Authorized HCPCS Codes
  • Medical Pharmacy Portal Step-by-Step Guide
  • Michigan Prior Authorization Request Form
Medical Authorizations
  • Medical Prior Authorization Request Form
  • Home Health Care Prior Authorization Form
  • MDHHS Medicaid Fee Schedule
DME Authorizations
  • DME/Medical Supply Prior Authorization Request Form
  • DME/Medical Supply Prior Authorization Request Form Guide
  • CMS Medicare DME Fee Schedule 
  • MDHHS Medicaid DME Fee Schedule
Other Forms
  • Care-Coordination/Case-Management Referral Form
  • Delivery Notification Form
  • Notification of Pregnant Member
  • Healthy Michigan Plan Health Risk Assessment
  • Information Update Form
  • Medical Needs Form – Fax completed form to UPHP
  • Price Negotiation Request Form
  • Release of Protected Health Information form
MDHHS Resources
  • Michigan Department of Human Services (MDHHS)
  • Healthy Michigan Plan
  • MDHHS Healthy Michigan Plan Copay Information Sheet
  • Children’s Special Health Care Services
  • Healthy Kids Dental
  • MIChild

Page Last Updated: 09/26/2018

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Upper Peninsula Health Plan
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(TTY 711)

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853 West Washington Street Marquette, Michigan 49855
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