Behavioral Health Outpatient Authorization Request Form

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Behavioral Health Outpatient Authorization Request Form
Fax to: 616.975.0249
Member information
Last name _________________________________
First name _________________________________
Priority Health ID # __________________________
Date of birth ________________________________
Type of request
 TMS
ADD/ADHD testing
Psychiatric
Psych testing
Therapy
 Medicare organization determination
☐ Substance use disorder- Intensive outpatient
Treatment provider name __________________________ Provider tax ID ______________________________
Group/facility name
________________________________________________________________________
Service address
________________________________________________________________________
For TMS requests, clinical record must be faxed with this form. For TMS medical policy criteria, go to
Select “Provider Manual” and then “Medical policies.”
For substance use disorder- Intensive outpatient concurrent reviews, clinical record must be faxed with
this form.
What is/are the specific mental health issue/s being addressed?
ADD/ADHD
Anxiety
Depression
Other (Please describe)
_________________________________________________________________________________
Any presence of the following?
Suicidal thoughts
Homicidal thoughts
Psychosis
Drug or alcohol withdrawal symptoms
Any current behavioral health services being received through Community Mental Health? No Yes
If yes, please specify: ________________________________________________________________________
Any hospitalization in a psychiatric setting within the past two years?
Yes No
Contact information of office administrator requesting the authorization:
Name ___________________________________________________________________________________
Address
____________________________________________________________________________
Type of office: Behavioral Health provider office
PCP office
Facility
Other
Phone / Fax ______________________________________________________________________________
Comments:
Priority Health office use only:
Received date ___________ Decision date __________ Date(s) of evaluation(s) (if available) _________________________________
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