Prior Authorization Home Health Care or Outpatient Therapy Request

This document serves as a request form for prior authorization for home health care or outpatient therapy. It includes fields for member information, provider details, and the types of therapy requested. The form emphasizes the importance of submitting requests in advance and attaching clinical notes to avoid delays. It also clarifies that authorization does not guarantee payment and provides contact information for eligibility inquiries. Confidentiality notices are included to protect sensitive information.