Prior Authorization Request Form

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Mercy Maricopa
4350 E. Cotton Center Blvd.
Building D
Phoenix, AZ 85040 Phone
(602) 263-3000 Toll Free
(800) 564-5465 Fax:
1-844-424-3976
ECT Prior Authorization Request Form
Date of Request:
Please check appropriate box:
PLEASE NOTE: Processing time 14 calendar days
Acute request
Inpatient
Outpatient
Extension of acute inpatient treatment
Request for maintenance treatment
Routine request is processed in 14 days
Please note that any request for maintenance treatment must be submitted as an initial request
Form must be completed in its entirety
Member Information: Current location ________________________________________
AHCCCS ID #:
Date of Birth:
Name:
Other Insurance If AHCCCS is not primary
Yes
No If yes, please specify:
Phone #:
N
Title XIX/XXI
Y
SMI
Y
N Clinic name
Y
N Clinic name
GMH
DDD
Y
N Please attach authorization from CMO of DDD
Coordination of care with the outpatient Behavioral Health Medical Provider is required.
i) If this is a request for acute, extension of acute or maintenance ECT, coordination of care is required with
the outpatient community mental health provider prior to approval.
ii) If member is currently inpatient and is not assigned to an outpatient BHMP, NOTE: you are required to
have the member assigned to a behavioral health provider in the network prior to discharge.
For DDD members an approval letter from DDD CMO is required and must accompany PA application prior to
consideration of ECT
Y
N
Has the BHMP agreed that this member is being referred for ECT
Name of BHMP
Date
(Outpatient treament behavioral health medical provider)
1

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