Skip to content

Outpatient Medical Services Prior Authorization Request Form

This form is for non-contracted providers. Contracted providers should submit authorization requests and check status online by logging in at and selecting Authorizations.

Please complete all fields below and include supporting clinical information (e.g., office visit notes, lab results, radiology results, etc.).

If you have any questions, call (313) 664-8950, option 1.

Please enter your email address for your registration confirmation email.

* are required fields

This form is for non contracted provider’s only. If you are contracted, please fax request to 313-664-5916 or submit through Care Affiliate.

This form is not for patients with Medicaid. All Medicaid requests will be processed by CareSource.

(Fax number to send completed authorization determination.)

Member Information

Ordering provider information

Servicing provider information

For surgical procedures, list the physician providing the service.

Servicing facility information

For surgical procedures, list the facility providing the service.

General authorization information

PLEASE NOTE-If you received a denial on a submitted claim, please follow the HAP Provider Appeals process and do not submit this authorization request. Please fax provider appeals to (313) 664-5640 (on the fax coversheet please include “ATTENTION APPEALS”). Or call (313) 664-8950, option 2

Service/items needed (list CPT/HCPCS codes and quantity for each service in the corresponding box below).

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

Supporting clinical information:

For all supporting clinical information, please attach any related files, list the name of the patient and their HAP ID in the body of the email, and send them to