Antipsychotic (6 Years Of Age) - Prior Authorization Form
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CHILDREN’S MEDICAL SERVICES NETWORK
Prior Authorization
Antipsychotic (<6 years of age)
180-day Maximum Approval
Note: Form must be completed in full. An incomplete form may be returned.
Recipient’s Medicaid ID#
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
-
-
Yes
No
PROVIDER TYPE OR SPECIALTY:
CHILD UNDER STATE CARE/CUSTODY:
Male
Female
New
Continuation
PATIENT:
MEDICATION REQUEST:
_________
in /
cm
lbs /
kgs
________
HEIGHT:
WEIGHT: ___________
BMI:
___________
*BMI %:
BMI Calculator: *
Antipsychotic Medication/Strength:
Target
Aggression
Diagnosis:
ADHD
Symptoms:
Self-Injurious Behavior
Autism Spectrum
_______________________________________
(check all that
Impulsivity
Disruptive Behavior Disorder
apply)
Irritability
Disruptive Mood Dysregulation Disorder
Quantity: _______________________________
Other
Other
_____________________
__________________________________
Directions:
________________________________________
_____________________
__________________________________
________________________________________
Severity of Target Symptoms
1 Mild
2 Moderate
3 Marked
4 Severe
5 Extreme
Functional Impairment:
1 Mild
2 Moderate
3 Marked
4 Severe
5 Extreme
Previous Therapy (Pharmacological and Non Pharmacological):
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Have metabolic monitoring labs* (fasting lipids and glucose) been performed within the last 6 months?:
Yes
No
*Official lab results (most recent) must be attached. For continuation of therapy, labs are required.
Date:_________________
Has an assessment for Tardive Dyskinesia been done in the last 6 months?
AIMS:
Yes
No
DISCUS:
Yes
No
*Official Form or notation (most recent) must be attached.
Date: __________________
Monitoring Plan: RTC: ________________________
Labs: q
months
TD Screen: q
months
Next appointment date: ________________________
Prescriber’s Signature: ___________________________________________________________
Date: __________________________
REQUIRED FOR REVIEW: Copies of medical records (diagnostic evaluation and recent chart notes), the original prescription, most
recent copy of related labs and most recent TD screen. The provider must retain copies of all documentation for five years.
Mail or Fax Information to:
University of South Florida, School of Medicine, Department of Psychiatry
Magellan Medicaid Administration, Inc.
Prior Authorization
USF Child Psychiatrist Review:
P. O. Box 7082
Tallahassee, FL 32314-7082
I do not recommend approval
I recommend approval for _______ months
Phone: 877-553-7481
Fax: 877-614-1078
USF Child Psychiatrist Signature:________________________________ Date: ___________
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