Service Authorization Request - Housing 816 Hour Group Home - Hawaii Mental Health Division Page 2
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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
Authorization Information Continued
Admission Criteria:
(Must Meet all of the following)
Risk Factors are manageable at this level of housing
Does not meet criteria for a higher level of care (e.g 24 GH ICF, SNF, SRSP, TLP, ARCH, E‐ARCH)
Presents a reduction in ability to function such as performing personal hygiene and bodily care activities, obtaining
adequate nutrition, sleep or becoming socially isolated
Continuation Criteria:
(Must meet one of the following)
Intensity of service being delivered continues to meet admission criteria:
If this is selected the request must be accompanied by a current treatment plan
Complications arising from initiation of, or change in, medication or other treatment modalities: If this is selected the
request must be accompanied by clinical documentation of the change in medication of other treatment modalities
Forensically Encumbered (Conditional Release, Released on Conditions, Mental Health Court, and Jail Diversion)
If this is selected the request must be accompanied by the court order specifying level of care or location
Consumer is experiencing symptoms of such intensity that admission to a higher level of care would likely occur upon
discharge
selected
. If this is
the request must be accompanied by clinical documentation of presenting symptoms requiring
continued care
Discharge Criteria:
Deceased
Unable to locate
Requires Higher LOC
Hospitalization
Clinically Ready For Discharge
Refuses Treatment
Incarceration
Moved from State/County
Other Discharge Criteria (please specify):
Discharge to:
Name(Last Name, First Name, Middle Initial) : ______________________________________________________________________
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