Adult Psychiatric Clinical Service Form

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BlueCare
SM
TennCareSelect
1 Cameron Hill Circle
Chattanooga, TN 37402
Adult Psychiatric Clinical Service
Authorization 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
¨ Crisis Stabilization
¨ Respite
¨ CCFT
¨ Psych Testing
¨ CTT
¨ Home Based Treatment
¨ Mental Health Care Coordination
¨ Supported Housing
¨ Enhanced Supported Housing
¨ Medically Fragile Supported Housing
Instructions
Complete this form for both initial and concurrent requests for services.
For Initial review, complete all items. For concurrent review, complete only items with an asterisk.*
Member Information
Member Name: ________________________________________________________
Member ID Number: ____________________________________________________
Date of Birth: __________________________________________________________
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
15ALM308 (2/15)

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