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Outpatient Authorization Change Request Form

Use this form to request changes to existing outpatient referrals or authorizations. The provider submitting this form must be listed as the requesting or servicing provider on the existing referral or authorization. 

The following types of changes can be requested online:

  • servicing provider
  • priority of the request (urgent to routine)
  • CPT® or diagnosis codes (not applicable for specialty referrals or mental health authorizations)*
  • procedure/surgery/service date(s)
  • number of visits/units*

Once submitted, your request will be processed within two business days. You can check status of your referral or authorization on our Check Status page. 

*If a primary care manager (PCM) refers a patient specifically for consultation or evaluation only, Health Net Federal Services, LLC may only issue a referral for an initial consultation visit or an initial consultation and one follow-up visit. These requests cannot be extended.

Please do not use this form to request new referrals/authorizations, submit medical documentation, request applied behavior analysis (ABA) changes, or to submit questions to customer service. 

 

* = required field

Date format: mm/dd/yyyy