Non-PHO Authorization Request

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Medical Out of Network Provider Authorization Request Form
Johns Hopkins All Children's Hospital Medical Authorization Request
Behavioral Health Authorization Request for Inpatient, IOP, Partial Hospitalization, Residential Treatment
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Authorization Request

If you are an SMH PHO physician office, do not use this form.
Click here to login and start the authorization in the appropriate Authorization section.

How will this information be used?

Authorization Request Type:

Out of Network Provider

SMH Genetic Testing

DME (Do not use for Out of Network Provider)

Tutorials:

Out of Area Out Of Network Request
DME Requests

You may retrieve an existing request by entering your case number.

Case Number: