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Provider Emergent Inpatient Admission 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., presenting clinical, lab results, radiology results, response to treatment, plan of care, etc.).

If you have any questions, call (313) 664-8833 option 3.

* are required fields

Member's information

Contact person's information

Servicing facility information

Servicing provider information

Patient's servicing information

Patient history

Clinical Findings

Vital signs prior to treatment

Vital signs after treatment

Treatment/Plan of care

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