Fillable Sex Offender Treatment Request Form printable pdf download

Sex Offender Treatment Request Form

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BlueCare

TennCareSelect

1 Cameron Hill Circle

Chattanooga, TN 37402

Sex Offender Treatment Request Form

Prior Authorization Fax Request Form

Authorization is not a confirmation of coverage or benefits. Benefits remain subject to all contract terms,

benefit limitations, conditions, exclusions, and the patient’s eligibility at the time services are rendered.

BlueCare/TennCareSelect

Fax Number: 1-866-320-3800

¨ BlueCare

¨ TennCareSelect

¨ Inpatient Request

¨ Outpatient Request

¨ Psych Acute I/P

¨ Psych Partial Hospitalization

¨ Psych Residential

¨ Psych IOP

¨ Psych Testing

¨ Home Based Treatment

¨ Mental Health Care Coordination

Instructions:

Use this form for Residential Treatment Center (RTC) Concurrent Review Requests ONLY-Initial RTC requests

should be made using the Psychiatric residential treatment facility (PRTF) form.

• For all other levels of care, complete this form for both initial and concurrent requests.

• For concurrent requests, complete ONLY items marked with an asterisk. *

Member Information

Member Name: ________________________________________ Member ID Number: ____________________

Date of Birth: _____________________________________________________ Age: ____________________

Department of Children’s Services (DCS) Custody: q YES q NO

If RTC, is member already admitted on DCS Letter of Authorization (LOA)? q YES q NO

Diagnosis: (List all DSM-5 codes) ________________________________________________________________

__________________________________________________________________________________________

This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or

your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby

notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received

this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via

the U.S. Postal Service. Thank You.

BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association

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