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Provider Referral Form – Request for Pre-Authorization

McLaren Health Plan
Phone: (888) 327-0671
Fax: (810) 733-9647

Service Codes requiring Pre-authorization

Printable Provider Authorization Form

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PATIENT INFORMATION
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REFERRED TO:
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(This authorization is for the services requested. The actual procedure codes billed may require additional documentation for reimbursement.)*
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Home Care Evaluation: (See comment section for authorized number of visits)
OUTPATIENT THERAPIES:
DME/Medical Supplies: (Pre-Authorization required for > $1500 purchase price and > $500 rentals)

This referral is not a guarantee of payment. Please contact McLaren Health Plan to verify eligibility and covered benefits.
All information, including any attachments are confidential and intended solely for the use of the intended recipient(s).
All information is privileged or otherwise protected from disclosure by applicable law. Any authorized disclosure, dissemination, use or reproduction is strictly prohibited.
If you have received this in error, please notify the sender immediately and destroy the information.
IF YOU WOULD LIKE A COPY OF THIS REFERRAL FORM, YOU MUST PRINT IT (AFTER THE FIELDS ARE FILLED OUT). GO THE MENU BAR SELECT FILE THEN PRINT. ONCE HITTING SUBMIT, YOU WILL NOT BE ABLE TO OBTAIN A COPY OF THIS FORM.