Forms and Links
MI Coordinated Health
Online Coverage Determination Request
(Clicking on this link will take you away from UPHP’s website)
UPHP MI Coordinated Health Medicare Coverage Determination Request Form
Request for Redetermination of Medicare Prescription Drug Denial Form
MI Health Link
UPHP MI Health Link Medicare Drug Coverage Determination Request Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Medicaid
Medical Drug Benefit (J Code) Information
UPHP Medicaid Prescription Prior Authorization Request Form
UPHP Medicaid Prescription Appeal Request Form
Michigan Medicaid (Fee for Service) Prior Authorization Request Form
Nonopioid Directive Form– The Michigan Department of Health and Human Services has developed a nonopioid directive form. This form lets patients inform their health care providers that they do not want to receive opioids. The form can be revoked at any time by telling the provider. Individuals (or legal guardians) who want to inform a health care provider of their wish may download and complete the form and give a copy to all their health care providers, including dentists.
- Medical Prior Authorization Request Form
- Medical Pharmacy (J Code) Drug Prior Authorization Request Form
- Home Health Care Prior Authorization Form
- UPHP Home Health Care Prior Authorization Tips
- MDHHS Medicaid Fee Schedule
- Skilled Care Notification and Update Form
- UPHP Clinical Submission Form
- UPHP Clinical Submission Form User Guide
- Group Information Update Form
- Personal Care Supplement Request for Reimbursement
- Appointment of Representative Form
- Care-Coordination/Case-Management Referral Form
- Delivery Notification Form
- Online Notification of Pregnancy Form
- Information Update Form
- UPHP Medical Needs Form – Fax completed form to UPHP
- Price Negotiation Request Form
- Release of Protected Health Information Form
Page Last Updated: 12/31/2025