Medication Management Services Only - Continued Stay Review Form - Maine Department Of Health And Human Services
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1Maine Behavioral Health ASO APS CareConnection® Authorization Request Form. Please submit this
information via APS CareConnection® whenever possible.
Medication Management Services Only - Continued Stay Review Form
Fields with a (*) next to them are required.
*Member MaineCare ID:
*Member SSN:
*Date of Birth: _____/_____/_____
*Member First Name:
*Member Last Name:
*Organization:
*Authorization Type: ___X___ Continued Stay Review
*Request Submission Date: ___/____/____
*Requested Start Date of Service: _____/_____/_____
*Review Type:
Adult Mental Health
Children’s Services
Psychological Services
*Date of Diagnostic Assessment: _____/_____/_____
*Primary Diagnosis:
Axis I Diagnosis I:
Axis II Diagnosis I:
Axis IV - Psychological Stressors: Write NONE, MILD, MODERATE, or SEVERE
Axis V Current (as appropriate):
Problems in Family Relations:______________________________________
Problems in Friendship/Social Relations:______________________________
Since last authorization, GAF score has:
Legal Issues:____________________________________________________
Increased
School Problems:________________________________________________
Decreased
Work Problems:_________________________________________________
Not Changed
Custody/Placement Issues:________________________________________
Unknown/NA
Financial Difficulties:_____________________________________________
Problems in Living Situation:_______________________________________
Physical Health:_________________________________________________
Problems with Access to Healthcare:________________________________
Other Psychosocial & Environmental Problems:________________________
*Service Code:
*Start Date: _____/_____/_____
*End Date: _____/_____/_____
*NPI Number:
*Service Length: 365 days
*Units:
*Is member prescribed medication?
Yes
No
Medications:
*Symptom:
*Severity: None;
*History of Severity:
*Symptom:
*Severity: None;
*History of Severity: 7
Mild; Moderate;
7 days; 8-90 days; 3-
Mild; Moderate;
days; 8-90 days; 3-12
Severe
12 months; 1-10
Severe
months; 1-10 years; 10+
years; 10+ years
years
Aggressiveness:
Self-Injurious Bx:
Sex. Inappropriate Bx:
Fire Setting:
Assaultive:
Suicide Attempt:
Homicidal Attempt:
Suicidal Ideation:
Homicidal Ideation:
Use of Weapons:
Self-Care Deficit
Harm to Animals:
Additional Information: Please provide additional information to support request for services, as needed.
*Treatment Progress:
Significant
Moderate
Minimum
None
Deteriorated
Other _______________________
*Provider Name: ___________________________________________________________________________
*Provider Signature: ________________________________________________________________________
*Date: _____/_____/_____
Medication Management Only Continued Stay Review Authorization Form V1-25-11
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