Outpatient Authorization Change Request Form

Use this form to request certain changes to active outpatient authorizations and referrals. The provider submitting this form must be listed as the requesting or servicing provider on the approval notice.

Use this form to request the following changes:

• servicing provider
• priority level
• CPT®, HCPCS® or diagnosis codes*
• procedure or service dates

*some exceptions apply

• If it has been more than 30 days since HNFS approved the services. Submit a new request instead.
  
• To add services to or extend visits/units on active approved authorizations. Submit a new request instead.
  • Tip: For services like physical/occupational/speech therapy and allergy visits, you can use a generic request type (e.g., P106) and specify codes needed for treatment.

  
  HNFS processes requests within five business days. Check the status on our Check Status page.

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