Forms and other information
We want it to be easy for you to work with HAP. Here are forms you'll need:
- Cotiviti and Change Healthcare/TC3 Claims Denial Appeal Form
- Outpatient Medical Services Prior Authorization Request Form To Be Completed by Non-Contracted Providers Only
- Provider Change Form (for network terminations and transfers)
- Inpt Rehab SNF-Admission Precert
- Inpt Rehab SNF-Continued Stay or Auth Discharge Summary
- Inpt Rehab SNF-LTAC Continued Stay Auth
- Inpt Rehab SNF-Wound Care Summary
- W-9 Form - Email completed W-9 forms to firstname.lastname@example.org. Be sure the form is signed and dated, or it will be returned.
- Provider – Waiver of Liability - 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.
Facility and medical record standards
- Facility Standards Outpatient Mental Health Chemical Dependency Facility Independent Practicing Practitioners
- Facility Standards Specialty Care and Ob/Gyn Practitioners
- Medical Records Standards Outpatient Mental Health Chemical Dependency Facility Independent Practicing Practitioners
- Medical Records Standards Primary Care Practitioners
- Medical Records Primary Care and Specialty Care Practitioners