Fillable Behavioral Health Pre-Authorization Form

Reset Form

Please fax form to CommunityCare Behavioral Health Services (CCBHS) at 918-879-4316 or 800-213-2956.

Questions? Call 918-594-5262 opt 1 or 800-774-2677 opt 1.

Behavioral Health Pre-Authorization Form

(Entire section must be completed unless indicated)

Patient Name:____________________________________________________ Member ID#:____________________________

DOB:_______/_______/_______

Date of Request/Admission:_______/______/_______

Requesting Provider:_____________________________Telephone#:_______________________Fax#:_______________________

Requested Service

(Please check the service you are requesting, write the number of units/sessions/days on the # line and requested dates of service.)

 Acute Inpatient Hospitalization: #__________ Dates of service requested __________________________________

 Acute Inpatient Detoxification: #___________ Dates of service requested __________________________________

 Residential Treatment: #__________ Dates of service requested __________________________________________

Problem List: ________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Specific Presenting Symptoms and Current Impairment:______________________________________________________________

___________________________________________________________________________________________________________

Suicidal/Homicidal/Psychotic? (If yes, please explain): _______________________________________________________________

___________________________________________________________________________________________________________

Alcohol/Drug Use: (List substances, amount, frequency, last use, & withdrawal symptoms):_________________________________

___________________________________________________________________________________________________________

Current Medications (

.):______________________________________________________________________

type, dosage, prescribing Dr

____________________________________________________________________________________________________________

Progress since Last Authorization: _______________________________________________________________________________

___________________________________________________________________________________________________________

Treatment Goal(s) & Interventions to Meet Goals:___________________________________________________________________

___________________________________________________________________________________________________________

If patient is a minor, list the date of the last family therapy session._____________________________________________________

Previous Treatment History: ____________________________________________________________________________________

___________________________________________________________________________________________________________

Discharge Plan & Estimated Date of Discharge:_____________________________________________________________________

___________________________________________________________________________________________________________

Signature & Credentials (

): _________________________________________________________________

of person completing the form

Note: If services are authorized, the certification will begin on the standard business day complete clinical information is received.

It is the facility or provider responsibility to ensure medical necessity.

Revised 01/2016

Behavioral Health Pre-Authorization Form - Ccbhs