Prior Authorization Request Form Page 4
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6Member:
AHCCCS ID Number:
a.
Target Symptoms:
b.
What will determine # of treatments? (Success or Failure, Outcomes Measure):
c.
Unavoidable adverse effects which are less likely or severe with ECT therapy:
Need for rapid definitive response on physical or psychiatric grounds:
d.
e.
Current mental status :
2) MEDICAL HISTORY:
Current Physical Health Care Providers:
1. PCP:
Name:
Phone:
2. Specialist: Name:
Phone:
Specialty:
3. Specialist: Name:
Phone:
Specialty:
Known Medication Allergies:
Current Non-Psychiatric Medications:
Pregnancy Status:
Known Medical Conditions:
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Parent category: Medical