The 42 Michigan forms clinicians complete, from Department of State driver and placard forms to MDHHS disability reports, drug prior authorization, MHSAA physicals and the MI-POST.
This page lists the Michigan forms clinicians complete, grouped by program, and each group links to its program hub. The Department of State sends DA-4P, the Physician's Statement of Examination, when a driver is referred for reexamination, and DA-4V to vision specialists. BFS-108 covers disability parking placards. MDHHS caseworkers send the DHS-49 Medical Examination Report for disability decisions and DHS-54A to verify a FIP client's incapacity. Health insurers take FIS 2288 for prescription drug prior authorization.
On FIS 2288, insurers must answer within 72 hours for expedited requests or 15 days for standard ones, or the request is deemed granted. The DHS-49 series is issued per case, not posted online. Workers' comp has one clinician form, the WC-728 Amputation Chart, signed by the operating surgeon. DTE, Consumers and other utilities use the same MPSC-approved medical certification to hold a shutoff. Of these forms, 3 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart.
WC-728Diagram on which the operating surgeon marks and certifies the exact point of amputation (and distance below elbow or knee for arm/leg) for specific-loss benefits.
Physician's diagnosis, prognosis, cognitive screening (MoCA, clock drawing, Trails A&B), loss-of-consciousness history and recommended restrictions for a driver referred for a driver assessment reexamination; also used to request a tinted-window restriction.
Vision specialist's report of acuity, peripheral fields, ocular diagnoses and recommended restrictions (incl. bioptic telescope section) for licensing or driver assessment.
Requests that the Department of State evaluate a person's ability to drive safely under MCL 257.320.
Applies for or renews a permanent or temporary disability parking placard, with certification by a licensed medical professional.
Licensed professional's documentation of the applicant's disability and functional limits, required with the SMART ADA Application for ADA paratransit certification in suburban Detroit.
Form a health care provider files to appeal an auto insurer's or the MCCA's utilization review determination (medical necessity and/or cost) under MCL 500.3157a and Mich Admin Code R 500.65.
Prior authorization request for DME, medical supplies, orthotics/prosthetics and other special services (non-mobility items) under Michigan Medicaid FFS/CSHCS.
Clinical evaluation and medical justification for complex seating systems, wheelchairs and mobility devices requested from Michigan Medicaid.
MSA-6544-BMichigan Medicaid fee-for-service (and CSHCS) prior authorization request for practitioner services.
BPHASA-2401Prescriber's medical justification for enteral nutrition therapy under Michigan Medicaid.
Home health agency request for prior approval of home health aide services under Michigan Medicaid.
MDHHS-3305Child health appraisal (exam, screenings, immunizations) used for enrollment in licensed child care centers, preschool/GSRP and school entry so the program can meet the child's health needs.
CCL-3704Physician statement requested by child care licensing on whether an applicant, licensee or household member has a physical or mental condition affecting the care of children.
Two-page medical history, physical examination and medical clearance required for MHSAA athletic participation each school year.
Unconditional written clearance from a medical provider plus student/parent consent before an athlete removed for concussion symptoms returns to activity.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Órdenes Médicas de Michigan para Alcance del Tratamiento (MI-POST)
Optional 1-page, 2-sided medical order recording CPR, critical care and other treatment wishes for people with serious advanced illness or frailty (Public Act 154 of 2017).
Examiner's report and clinical certificate stating whether an individual requires involuntary mental health treatment (hospitalization, assisted outpatient treatment or combined), after the statutory advisement is read.
Court-appointed examiner's report on an alleged incapacitated individual's infirmities, decision-making ability and need for a guardian (MCL 700.5304).
Clinical supplement filed when an individual on an assisted outpatient or combined order appeals a return to the hospital or facility (MCR 5.743a).
Examiners' certification on whether an individual with an intellectual disability meets criteria for judicial admission to a facility, with recommended treatment and alternatives.
Michigan physician certifies the patient's debilitating medical condition(s) (Categories A-C) and a bona fide physician-patient relationship for a medical marijuana registry card.
Two Michigan physicians each certify a minor patient's debilitating medical condition for a medical marijuana registry card.
Web-based mandatory reporting of communicable diseases by physicians, labs and facilities to the local health department.
Online report of suspected child abuse or neglect by mandated reporters (alternative to the hotline plus DHS-3200).
Report of Actual or Suspected Child Abuse or Neglect (Spanish) DHS-3200-SP
Mandated reporter's written follow-up report to Children's Protective Services after a hotline report of suspected child abuse or neglect.
MDHHS Form 1355Medical provider's case report of HIV infection in an adult or adolescent (in addition to electronic lab reporting).
Physician or public health official certifies a medical emergency (21-day shutoff hold, up to 63 days with renewals) or critical-care status (annual hold for home medical/life-support equipment) for a DTE customer's household.
Form 2330Physician or public health official certifies a medical emergency (21-day shutoff hold, max 63 days) or critical-care customer status (annual) for a Consumers Energy household.
Certification by a physician, PT or OT (functional draw test, manual muscle test, range-of-motion test, or physician criteria such as amputation or permanent wheelchair use) for a permit to use a crossbow or modified bow in restricted archery seasons.
PR9409Certification by a licensed physician or physical/occupational therapist (coordination assessment, or physician diagnosis of amputation, paraplegia, spinal cord injury) that a permanently disabled hunter cannot walk in a hunting situation, for a permit to hunt from a standing vehicle or PMAD.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A physician, MD or DO. The DA-4P covers diagnosis, prognosis, cognitive screening (MoCA, clock drawing, Trails A and B), loss-of-consciousness history and recommended restrictions for a driver referred for reexamination, and it can also support a tinted-window restriction. Return it to the Driver Assessment Section as the notice directs. Vision specialists complete Sections 3 to 7 of the separate DA-4V.
The treating physician, MD or DO. MDHHS or Disability Determination Service sends it per case and uses the exam findings, diagnoses and physical limitations to certify disability for State Disability Assistance, FIP deferrals and Medicaid. Mental health conditions use DHS-49-D and DHS-49-E, completed by a psychiatrist or fully licensed psychologist, and eye cases use DHS-49-I. DDS may pay for reports it requests.
A physical counts for the school year if it was given on or after April 15 of the previous school year. An MD, DO, PA or NP completes the Physical Examination and Medical Clearance section on page 1, and the patient gives the form to the school. The MHSAA physical comes in Spanish and Arabic. After a concussion, the MHSAA return form needs an unconditional written clearance.
A physician or public health official completes Section 3 of the utility's MPSC-approved Medical Certification Form, used by DTE, Consumers Energy and other Michigan utilities. A medical emergency gives a 21-day hold, up to 63 days with renewals. Critical care status for home medical or life-support equipment gives an annual hold that must be renewed each year. The customer returns the form with ID within 3 business days.