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 hap.org 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

*Member name (first and last) *HAP or HAP Empowered member ID number (11 digits): *Member’s date of birth:

Contact person's information

*Contact person name: *Contact person phone number: *Contact person email Confirm Email

Servicing facility information

Facility name (if applicable): *Facility NPI: Facility address (if applicable): *ICD 10 diagnosis code(s):

Servicing provider information

*Physician name (first and last): *Physician NPI: *Physician phone number: Physician fax number:

Patient's servicing information

*Date admitted: Discharge date (if applicable): Discharge disposition (if applicable): *Primary admitting diagnosis: CPT(s) if surgical intervention took place:

Patient history

*Past medical history: *Past surgical history:

Clinical Findings

*Presenting signs and symptoms: Imaging findings relevant to admitting diagnosis: Laboratory findings relevant to admitting diagnosis: Findings of any other diagnostic tests relevant to admitting diagnosis:

Vital signs prior to treatment

Temperature: Heart rate: Respiratory rate: SpO2: Room air or oxygen delivery and Liters or %:

Vital signs after treatment

Temperature: Heart rate: Respiratory rate: SpO2: Room air or oxygen delivery and Liters or %:

Treatment/Plan of care

*Emergency room treatment: *Member response to treatment: *Plan of care: *I agree to send all supporting clinical information, to the ADM_Team@hap.org email.

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

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