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Michigan Department of Health and Human Services

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Prior Authorization Forms Last Modified
Prior Authorization Forms Last Modified
ADD/ADHD Therapy Over Age 17 Years - Request PA by Fax Form (NPI compliant) 06/08/2017
Alcohol Abuse Treatment - Request PA by Fax Form 05/30/2017
FSS 2288 Form for Prescription Drugs 10/29/2015
Hemophilia Case Review Form 12/27/2016
Hepatitis C Medications - Request PA by Fax Form 01/26/2018
Kalydeco, Orkambi and Symdeko - Request PA by Fax Form 07/18/2018
Opioid Abuse Treatment - Request PA by Fax Form (NPI Compliant) 08/08/2017
Opioid Abuse Treatment - Sublocade - Request PA by Fax Form (NPI compliant) 05/31/2018
Request PA by Fax Form (NPI compliant) 05/30/2017
Stimulant Therapy for Diagnoses Other Than ADHD - Request PA by Fax Form 06/08/2017
Synagis - Request PA by Fax Form 10/25/2016
Xenical - Request PA by Fax Form (NPI compliant) 10/25/2016
Other Forms Last Modified
Other Forms Last Modified
EFT/835 Forms external link