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