CPST Prior Authorization Form for Continued Services

OH Mental Health and Addiction Services

CPST Prior Authorization Form for continued services

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Referral Information
Date Sent to Permedion:
Provider Name:
Contact Person:
Email address:
Phone: / Fax:
Address, City, St, Zip:
Provider NPI Number:
Recipient Information
Recipient Last Name: / First Name: / Suffix:
Social Security #: / Medicaid ID#:
Gender: / Male / Female
Race: / DOB: / Age:
Marital Status: / Single / Married / Divorced
Widowed / Other: (explain)
Address:
City, St, Zip:
Telephone:
Responsible Party Information
Responsible Party (Last Name, First Name)
Address:
City, St, Zip:
Telephone: / County:
Relationship: / Self / Parent(s)/Guardian / Court
Gov. Agency / Other: (explain)
Living Arrangements: / Alone / Court Ordered / Group Home / Group Home/Half-Way House
Homeless Shelter / Non-Relatives / Foster/Therapeutic Foster Home
Parents/Guardian / Spouse/Significant Other / Other: (explain)
Initial Treatment
Axis I (Primary) / ICD-9/10
Additional Axis I: / ICD-9/10
Additional Axis I: / ICD-9/10
Additional Axis I: / ICD-9/10
Axis II: / ICD-9/10
Axis III (Primary): / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Additional Axis III: / ICD-9/10
Axis IV: Psychosocial and Environmental Problems (“X” and explain all that apply)
Problems with primary support group
Problems related to social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to Health Care Services
Problems related to interaction with legal system
Other psychosocial and environmental problems
Axis V: / Current GAF: / Past Year GAF:
Mental Status
Please “X” and explain all that apply
Auditory hallucinations
Visual hallucinations
Delusions
Paranoia
Bizarre thinking
Thought content
Anxiety level/Panic Attacks
Appearance
Mood
Affect
Behavior
Speech
Cognition
Insight/Judgment
Sleep
Hygiene
Appetite:
Weight Loss/Gain:
Risk of Harm
Risk of Self Harm (please “X” all that apply and explain
Suicidal
Current Self Harming behavior
Explain:
Current or Past Risk of Harm to Others (Please “X” and explain all that apply)
Threats to Others
Violence or Assaultive Behavior
Sexual Promiscuity
Current Medications
Please list all current mediations:
Drug Name / Daily Dosage / Frequency / Start / Diagnosis
Complaint with Current Medications? / Yes / No / Not Applicable
Substance Abuse History
Please complete all applicable rows
Drug Name / Frequency / Last Use / Route / 1st Time / Amount per Use / Comments
Alcohol
Cannabis
Hallucinogens
Benzodiazepines
Inhalants
Amphetamines
Barbiturates
Narcotics
OTC Meds
Other
Impact of Substance abuse on treatment: (explain below)
Clinical Information
Needs assessment to succeed in the Community
Update to ISP and Progress or lack of progress towards ISP Goals
Clinical Information
Other Mental Health Interventions/Services (Please complete for each facility). Include Health Home for SPMI enrollment; is the Health Home engaged in this admission
Agency/Facility Name / Type of Service / Dates of Service / Frequency of Service (hours /day)
Justification for continued services more than 104 hours
Abuse (Physical, Emotional, Sexual, Neglect, Elder, Other
Please “X” all apply and explain
Recent Abuse
Past Abuse
Additional Information:
Units Requested
How many total hours/days of service have been used?
How many total hours/days are you requesting?
Are any of these units for retroactive purposes? / Yes / No
If Yes, how many units are for retroactive services?
Requested Start Date:
I affirm all information is a true and accurate description of the above individual.
Completed by:
Date:

Revised: 7/3/2013