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Authorization

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

This form is completed by providers and members (who have an HMO, PPO, EPO, or Indemnity health plan) when a health care provider leaves the network.

Providers and members complete this form to request continued care at certain higher-cost facilities, and pay lower costs for services, for up to one year.

Use this form ONLY for habilitative services. Habilitation services are defined as health care services that help a person keep, learn, or improve skills and functioning for daily living.

Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

For instructions on how to complete the form, refer to our Guide.