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Forms and Links

Pharmacy
  • 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
Medical
    • Medical 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
Durable Medical Equipment (DME)
  • DME Manually Priced Code Form
  • 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
  • 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
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: 08/12/2021

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