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Provider Forms 

You'll find all forms we currently use in the following list.

We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.


Other Forms

Consent for Sterilization (PDF 26.48 KB)

Asthma Action Plan (PDF 119.05 KB)

Certificate of Specialty Services (PDF 33.6 KB)

Claims Inquiry Status Form (PDF 48.24 KB)

Consent Submission Form (PDF 411.18 KB)

Delivery Admission Review Form (PDF 47.24 KB)

Diabetes Checklist - MQIC  (PDF 14.51 KB)

Gold - COPD Therapy Stages (PDF 29.58 KB)

Health Risk Assessment for Healthy Michigan: Letter (PDF 348.18 KB) | Assessment (DOCX 702.18 KB)

2016 Mileage Reimbursement Instructions (PDF 22.52 KB)

2016 Mileage Reimbursement Form (PDF 21.65 KB)

MDCH Maternal Infant Health Program Bulletin & Forms (PDF 1.24 MB)

Meals and Lodging Prior Authorization Form (PDF 97.72 KB)

Maternal Support Services (MSS) Screening Tool (PDF 26.5 KB)

Medical Record Documentation Review (PDF 33.75 KB)

UnitedHealthcare Community Plan Site Review Tool (PDF 78.54 KB)

Waiver of Liability Statement (PDF 79.02 KB)  

Sleep Study Worksheet (PDF 192.95 KB)