Sex Offender Treatment Request Form Page 2
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4Physician and Facility Information
¨ Initial Request
¨ Concurrent Review
Ordering Physician/Practitioner: ________________________________________________________________
Provider Tax ID Number ______________________________________________/NPI: ____________________
Phone Number: ______________________________Fax Number:_____________________________________
Date of Order: _________________________________________________________
Certificate of Medical Necessity:
1
st
Certificate of Need (CON): Date _____________________________________ Time ____________________
2
nd
CON: Date _____________________________________________________ Time ____________________
Facility Name: ______________________________________________________________________________
Provider Tax ID Number: _____________________________________________/NPI: ____________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
Utilization Review (UR) Contact Name: ___________________________________________________________
UR Phone Number: _____________________________________
Requested Start Date for Authorization: _____________________
Clinical Information
Date of Current Assessment: _____________________________ *Date of admission: ____________________
*Presenting Problem (behavioral description of current behavioral issues and changes since admission): _________
__________________________________________________________________________________________
*What is the current involvement with the legal system and/or DCS? ___________________________________
__________________________________________________________________________________________
*Has the member had a psycho sexual assessment performed by an approved sex offender treatment provider
that is qualified to determine the current behavior/risk? What level of care has been recommended?
__________________________________________________________________________________________
__________________________________________________________________________________________
When do these behaviors tend to happen? _______________________________________________________
__________________________________________________________________________________________
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.
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