Service Authorization Request - Housing 816 Hour Group Home - Hawaii Mental Health Division
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1
2Utilization Management
PO Box 3378
Honolulu, Hawaii 96801‐3378
Phone: 453‐6904, 453‐6981
Fax: 453‐6995
Housing 8‐16 Hour Group Home
Service Authorization Request
All fields are mandatory. UM may send back requests that are inaccurate or missing fields. The provider may not add additional fields, categories or otherwise
amend this form in any way. Requests for authorization must be submitted to UM within thirty (30) days of the provision of service.
Consumer Information
Name(Last Name, First Name, Middle Initial) : ______________________________________________________________________
Date of Birth: _______________________
SSN: _____________________________
Phone: ___________________________
No
No
Is this Consumer Homeless: Yes
Is this Consumer a Veteran: Yes
Diagnostic Information
ICD 10 Code: __________________________________________
ICD 10 Code: __________________________________________
ICD 10 Code:__________________________________________
ICD 10 Code: __________________________________________
A minimum of one AMHD eligible ICD‐10 code is necessary for authorization.
Case Manager Information
CBCM Agency: ________________________________________
Name of Case Manager: _________________________________
Case Manager’s Phone: _________________________________
Case Manager’s Fax: ____________________________________
All Housing services require linkage with case management.
Provider Information
Agency: ______________________________________________
Submitted by: _________________________________________
Phone: ____________________________
Fax: ______________________________
Date of Submission: __________________
Signature of staff submitting request: _____________________________________________________________________________
Housing Site Information
Address: ________________________________________
City: ____________________________________________
State: ___________________________________________
Zip Code: ______________________________________
Note the site information must correspond with the specific site that is contracted with AMHD.
Authorization Information
Admit
Date: _________ Cont.
Date: _________ Discharge
Date: _________
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