Home Page

Completion of this form by the health plan is required to schedule a non-participating Michigan Medicaid HMO member at UMHS.

1. Provider Information

* Primary Care Physician (PCP)

Last Name:

First Name:PCP info required

Phone #:

Fax #:

Address:

County:

Referring Physician (if other than PCP)

Last Name:

First Name

Phone #:

Fax #:

Address:

County:

2. Referral Reason

Continuation of Care (Extends previously authorized care, adds another service not included in the previous authorization, or authorization for services when the patient had a change in health plan coverage in the middle of care.)

In-network specialist unable to treat (Patient was evaluated by an in-network provider and referred to Michigan Medicine for additional evaluation and treatment.)

Specialty not available in-network (The health plan has no contracted providers for the requested specialty.)

In-network specialist refusing referral (The health plan’s contracted provider will not accept the referral.)

Group Name: Or Specialist Name: First Last

3. Patient Information

Name: First

LastRequired field Birthday(mm/dd/yyyy):Birthday required

County:

Phone #: Home

Work Alternate

Parent/Guardian Name:

Parent/Guardian Phone:

4. Health Plan Preliminary Service Requested

Health Plan Name:

Health Plan ID #:

ID # required Medicaid Recipient ID #: Recipient ID # required

* Service Requested & Medical Information

UMHS Specialty:

Physician name:

* Service Type

Office Visit and Treatment (This includes routine test and treatment associated with the Office Visit.)

Number of Visits:

# of visit required Start Date: End Date:

Diagnosis/ICD-9:

Diagnosis/ICD-9 required

Procedures/CPT:

Symptoms/Comments:

* Health Plan Authorization

Authorization # (Physician & Facility Services):Anthorization # required

* Completed By Name:Completed by name required Phone#: Completed by phone required Ext:

5. UMHS Staff Only

Important Notice: Additional health plan authorization may be required for non-routine testing and complex treatment. Verify authorization requirements with the health plan. Contact the health plan or PCP for authorization extensions.

Medicaid Specialty Access Form(for non-contracted Michigan Medicaid HMO plans)

Medicaid Specialty Access Form
(for non-contracted Michigan Medicaid HMO plans)