Documents and Forms
All Documents and Forms
The Provider Manual has everything you need to know about member benefits, coverage, and provider guidelines. Click the link below to view or save a copy.
- Primary Care Provider Reassignment Form - (PDF)
- Care Coordination/Complex Case Management Referral Form - (PDF)
- MSA-1302 Beneficiary Monitoring Primary Provider Referral Notification/Request Form - (PDF)
- Inpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Form (PDF)
Mental Health Forms:
- Behavioral Health Discharge Transition of Care Form - (PDF)
- Outpatient Psychological Testing Authorization Request Form - (PDF)
Medical Records & Data Forms:
Diabetic Medical Supply Form:
COPD Home Program Form:
Sterilization Informed Consent:
Maternal Infant Programs:
Community Health Workers (CHWs) Information:
Patient Communication Assessment Tool (PDF) - This tool is meant to help deaf, hard-of-hearing, late-deafened, deaf-blind, low/no vision, close vision, minimal-language, and/or speech loss patients receive effective communication via individual communication modes that best suit their needs.
Attestation Forms
- Well-Care Visit Form (PDF)
- Women's Care Form (PDF)
- Diabetes Care Form (PDF)
- Prenatal and Postpartum Care Form (PDF)
Exclusion Forms:
- Breast Cancer Screening Exclusion Form - (PDF)
- Cervical Cancer Screening Exclusion Form - (PDF)
- Diabetes Exclusion Form - (PDF)
P4P/PCMH Program:
Links:
Healthy Michigan Plan beneficiaries are encouraged to work in collaboration with their health care provider to establish annual health goals. The Healthy Michigan Plan HRA should be completed by member and provider together and faxed to the health plan at 833-341-2052. For a HRA to be considered complete the provider must complete all of section 4. Please visit the MDHHS Health Risk Assessment for HRA resources and templates.
Primary Care Provider Uplift - Payment Review Action Request Form
Request for Claim Dispute Form (Dates of Service 3/31/2022 and before)
Request for Claim Dispute Form (Dates of Service 4/1/2022 and after)
Links:
Ambetter Manuals & Forms
For Ambetter information, please visit our Ambetter website.