Prior Authorization / Adult Mental Health Day Treatment Attachment (Pa/amhdta) Page 2

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PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA)
Page 2 of 4
F-11038 (07/12)
SECTION III — DOCUMENTATION (Continued)
11. Attach Section I of the member’s most recent Functional Assessment. (The Mental Health Day Treatment Functional
Assessment, F-11090, must be signed and dated within three months of receipt by ForwardHealth.)
12. Is the member’s intellectual functioning below average?
Yes
No
If “yes,” what is the member’s IQ score or intellectual functioning level, and how was this measured?
13. Provide a brief history pertinent to requested services. (Include psycho-social history, hospitalization history, family history, living
situation history, etc.)
14. Describe progress / status since treatment began or was last authorized, if applicable.
Continued

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