MI HAP Provider Prior Authorization Request Form 2025

1. Click ‘Get Form’ to open the MI HAP Provider Prior Authorization Request Form in our editor.
2. Begin by filling out the 'Patient Information' section. Enter the member's ID number, last name, first name, date of birth, and phone number. Ensure all required fields marked with an asterisk (*) are completed.
3. Indicate whether the request is routine or urgent by selecting the appropriate option. Then, provide the member's address details including city, state, and ZIP code.
4. Attach any necessary clinical notes regarding history and prior treatment. Specify if the service is for inpatient or outpatient care and select the place of service from the provided options.
5. Fill in the 'Ordering Provider' information including name, tax ID, NPI, address, phone number, city, state, and ZIP code. Also include the start and end dates of service.
6. Complete the 'Facility/Servicing Provider' section similarly by providing their details along with diagnosis codes (DX Code) as applicable.
7. In the 'Additional Information' section, enter CPT/HCPCS codes along with quantity and description of services requested. Include any relevant insurance information and contact details for follow-up.

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