Comprehensive Community Support Services (CCSS)
Prior Authorization Form
*(post 72units utilized in 90day segment)
* Email form to: or Fax to: 1-877-296-1152
1. GENERAL INFORMATION
consumer name (first/last): consumer id or ssn:
consumer date of birth:
provider name: reviewer name:
provider/reviewer phone#: fax #:
requested start date of service:
# requested additional units:
2. CUSTODY (check all that apply):
cyfd tribal social services jppo/appo
3. WAIVER STATUS: Wait list Enrolled
MF DD D&E HIV CoLTS Mi Via
4. TARGET POPULATION:
children with serious emotional disorders (sed); or
adults with severe mental illness (smi); or
consumers with chronic substance abuse; or
consumers with co-occurring disorder (mental illness/substance abuse or dually diagnosed with a
primary diagnosis of mental illness)
5. PRECIPITATING EVENT REQUIRING ADDITIONAL UNITS :
crisis/crisis stabilization:
chronic condition requiring additional community support:
additional ccss required to complete the service plan or discharge plan:
complex case elements:
other:
6.. CONSUMERS’ PRIMARY DIAGNOSES TO SUBSTANTIATE NEED:
7.. CONSUMER GOALS TO ACHIEVE SERVICE PLAN:
8. HOW WILL THE ADDITIONAL UNITS HELP MEET THE GOALS OF THE SERVICE PLAN:
OHNM UM CCSS Review Form 052009 2