Please note:

As of November 2017 we have a more efficient fax number: 1-888-400-5786.

 

We are in the process of changing that number on the forms below.  In the mean time both numbers will work but, feel free to utilize our new fax number 1-888-400-5786.

 

Himmel Home Health Referral Form 2015

Superior Prior Auth Request Form Blank
Superior Prior Auth Request Speech Therapy IE
Superior Prior Auth Request Occupational Therapy IE
Superior Prior Auth Request Physical Therapy IE

Community First Authorization Form

Please download the PDFs then open to enable editable fields. Opening in your browser may prohibit this. Please use Google Chrome or Internet Explorer to open these forms, as they are not compatible with Firefox.

Please type in the information and print it for faxing purposes. Do not email with any Protected Health Information.