Forms and Links
- 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.
- Opioid Point-of-Sale Edits
- Prescription Prior Authorization/Medicaid
- UPHP Advantage and Choice Part D Coverage Determination Request Form
- UPHP MI Health Link Part D Coverage Determination Request Form
- Medical Pharmacy Prior Authorized HCPCS Codes
- Magellan Rx Medical Pharmacy Portal
- Michigan Prior Authorization Request Form
- Synagis Prior Authorization 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
- Healthy Michigan Plan Health Risk Assessment
- Information Update Form
- Medical Verification for Transportation – Fax completed form to UPHP
- Price Negotiation Request Form
- Release of Protected Health Information Form
Page Last Updated: 09/22/2022