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Inpatient Rehab/SNF and Emergent Admissions Form

Instructions: Complete form and fax to the number above. We follow InterQual criteria for review.

HIPAA regulations prohibit sending more clinical information than is needed for pre-cert. Do not submit the entire medical record. Only submit the information required on this form or the requested attachments. Please include H&P, pertinent consults, and last MD progress note available with all requests.

Please enter your email address for your registration confirmation email.

* are required fields

Note: Prior authorization is not required for long-term basic care placement at nursing center. LTAC is a hospital specializing in treating patients requiring extended hospitalization. For a list of contracted LTACs, visit; select Find a doctor; facilities/pharmacies; then narrow search by specialty and select long term care hospital.



Please check, fill in, circle all applicable items

(If > 1 wound include wound consult and current wound note)

Centimeter size:

1) Ventilator care: include 3 days respiratory notes:

a) Weaning trials:
b) Trach care:


Please fax therapy evaluations and current therapy notes (done within 24 hours for IPR request; done within 48 hours for Skilled: Physical Therapy, Occupational Therapy and Speech Therapy)

HAP will provide verbal authorization for transfer of the member. Admitting facility must notify HAP Admissions within 24 hours of the member’s arrival. Call (313) 664-8833 (option 1) or (800) 288-5959. The facility will receive the HAP auth number upon arrival.

Upon clicking the Submit button, the form contents will be submitted to HAP.

Specified skilled service information:

For all supporting specified skilled service information, please attach any related files, note specific to the request above, list the name of the patient and their HAP ID in the body of the email, and send them to