Therapeutic Behavioral On-Site Services for Children & Adolescents’ Re-Certification Request

Date:

Submission of this form constitutes a request for re-authorization of coverage for Therapeutic Behavioral On-Site (TBOS) services for the member referenced below. Complete information is required for AMERIGROUP to complete the review of this request. A licensed mental health clinician must sign this form prior to coverage authorization of TBOS services. Fax completed and signed referral forms to 1-866-495-1981, ATTN: Behavioral Health Case Management. Thank you.

Male Female
Member name / Member ID
(Medicaid or Amerigroup #) / Age / Date of Birth / Sex
SED EH ESE / Dates N/A
Grade / Special Education Other-specify / Out-of-School Suspensions within the last 3 months
Adapt Behavioral Services / 326476
Agency / Referring clinician / Provider number
( 407 ) 622-0444 / ( 407 ) 699-0444 /
Telephone number / Fax number / Email
Provide specific details of behaviors & symptoms within the last month in home/school environments which necessitate the continuance of TBOS services to prevent a more restrictive behavioral health placement
Describe specific changes in the treatment plan directly related to interventions & treatment modality/frequency
Describe in detail the aftercare/step down plan by identifying agency and services needed
List any & all current medications as well as psychiatric medications including dose and frequency None
Medication / Dose / Frequency
Code / Diagnosis
I
II
III
IV
V
List family members, caretakers,
or legal guardians that have
participated in therapy
*Please note:
Automatically submit
(If available)
Past 3 psychiatric evaluation notes, past 2 months of TBOS treatment notes, most recent updated treatment plan including any other clinical documentation that would be helpful.
List any current or past medical and surgical conditions None
Date / Conditions/diagnosis

Maximum number of requested units per Medicaid handbook cannot exceed 36 units (9 hours/month) for combined HO (therapy) and HM (behavioral management). HN units cannot exceed 128 units (32 hours/ month). Approved units will not exceed 6 months

TBOS units
16 units = 4 hr/month
20 units = 5 hr/month
24 units = 6 hr/month
28 units = 7 hr/month
32 units = 8 hr/month
36 units = 9 hr/month
HO units per month / HM units per month / HN units per month

I hereby certify as a clinician of the healing arts of behavioral health that I have reviewed this authorization for the above Amerigroup member and he/she meets the Medicaid Community Mental Health Handbook’s criteria for TBOS services.

PY4781
Clinician’s Signature Credentials / Date

7/15/2007 Page 1 of 3

FL Plan