Prior Authorization Substance Abuse Daily Treatment Attachment Page 2
Download a blank fillable Prior Authorization Substance Abuse Daily Treatment Attachment in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Prior Authorization Substance Abuse Daily Treatment Attachment with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA)
Page 2 of 4
F-11037 (07/12)
SECTION III — DOCUMENTATION (Continued)
8. List the current primary and secondary diagnosis codes and descriptions from the most recent Diagnostic and Statistical Manual
of Mental Disorders for the member’s current primary and secondary diagnosis.
9. Describe the member’s current clinical problems and relevant clinical history, including substance abuse history. (Give details of
dates of abuse, substance[s] abused, amounts used, date of last use, etc.)
10. Has the member received any substance abuse treatment in the past 12 months?
Yes
No
If “Yes,” provide information on the date of each treatment episode, the type of service provided, and the treatment outcomes.
11. Has the member received any inpatient substance abuse care, intensive outpatient
substance abuse services, or substance abuse day treatment in the past 12 months?
Yes
No
If “Yes,” give rationale for appropriateness and medical necessity of the current request. Describe projected outcome of
additional treatment requested.
Continued
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal