Prior Authorization Request Form Page 6

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Member:
AHCCCS ID Number:
EKG (within 30 days and reviewed by your medical consultant )
If female please provide negative UPT (last 7 days) or if pregnant provide documentation of consult and evaluation by
OB/GYN
Medical consultant review and clearance
opinion on the nature of unstable or serious medical conditions
As indicated (e.g. osteoporosis, osteopenia, history of skull spinal trauma) X-Rays of the Spine- Lateral X-rays of the
dorso-lumbar spine to rule out any spine fracture, before giving ECT, — Skull X-Rays - Anteroposterior and lateral view
of skull to screen intracerebral pathology before ECT.
When indicated, does the pcp agree with this member receiving ECT ___
Y
___
N
IF member 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.
If this is a request for ongoing ECT, coordination of care is required with the outpatient community mental health provider.
For maintanence ECT has coordination of care been completed with the outpatient BHMP Y
N
Date
Please provide the following copies of:
1. H & P
2. Psychiatric Eval
3. ECT Consultation
IMPORTANT: Failure to provide complete documentation specific to the request will result in
delayed processing times
Authorization does not guarantee payment. All authorizations are subject to member eligibility on the date of
service. If member is determined ineligible, the member may be responsible for these services. To ensure
proper payment for services rendered, referral provider/facility must verify eligibility on the date of service.
Verify benefit coverage in the benefit matrix located @
https://
6
QB 2957
Revised 6/8/17 JS

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