Prior Authorization Substance Abuse Daily Treatment Attachment Page 4
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4PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA)
Page 4 of 4
F-11037 (07/12)
SECTION III — DOCUMENTATION (Continued)
13. Treatment Plan (Continued)
•
Briefly describe treatment goals and objectives in specific and measurable terms.
•
Describe the expected outcomes of treatment including the plan for continuing care.
I have read the attached request for PA of substance abuse day treatment services and agree that it will be sent to ForwardHealth
for review.
14. SIGNATURE — Member or Representative
15. Date Signed
16. Relationship (If Representative)
17. SIGNATURE — Rendering Provider
18. Date Signed
19. Discipline of Rendering Provider
20. SIGNATURE — Supervising Physician or Psychologist
21. Date Signed
22. Supervising Physician or Psychologist’s NPI
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