We want it to be easy for you to work with HAP. Here are forms you’ll need:
- Outpatient Medical Services Prior Authorization Request Form (PDF) To Be Completed by Non-Contracted Providers Only
- LTAC Continued Stay Certification (PDF)
- Recovery Care Facility Pre-Cert Form (PDF)
- Recovery Care FacilityContinued Stay Certification (PDF)
- Recovery Care Facility Wound Care Summary (PDF)
- Transfer letter (PDF)
- W-9 Form (PDF)
- Provider – Waiver of Liability (PDF) - To file an appeal, a noncontracted doctor or other noncontracted provider who has furnished a service to the enrollee must complete and submit the Waiver of Liability form with their appeal request. This form is required by Medicare and must be received before we can begin to process the appeal. For HAP Empowered MI Health Link appeals, this form applies for Medicare-covered services.
Looking to become a HAP provider? Learn more.