Sandhills Center Service Authorization Request (SAR)

Sandhills Center –Service Authorization Request (SAR)

(See attached form for Dimension scoring instructions)

LOCUS

CALOCUS

/ 1 2 3 4 5 / Composite Score / LOC Recommendation
I. Risk of Harm
II. Functional Status
III. Co-Morbidity
IV- a. Recovery Environment. (Support)
IV-b. Recovery Environment. (Stress)
V. Resiliency and Treatment History
VI-a. Acceptance/Engagement (C&Y)
VI-b. Acceptance/Engagement (Parent/PS)
Comments:
Patient’s Name:
Social Security #: / DOB:
Current Address:
City/State/Zip:
Medicaid #: -- None / County (Medicaid Eligibility):
Attending Provider:
Legal Guardian: None Parent DSS Other: / Name:
DIAGNOSES (Indicate Primary Diagnosis with P):
DATE OF INITIAL ASSESSMENT and/or Subsequent Assessments prior to referral:
MH SA Voluntary Involuntary
Initial Request Reauthorization Discharge ** EXPEDITED**
SUBSTANCE USE
Drug of Choice N/A / Age of 1st Use / Route of Usage / Frequency / Amount / Date of Last use
Primary: 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Secondary: 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Tertiary: 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
Other: 00-None01-Alcohol02-Cocaine/Crack03-Marijuana / Hash04-Heroin05-Non-presc. Methadone06-Other Opiates/Synthetic07-PCP08-Other Hallucinogens09-Methamphetamines10-Other Amphetamines11-Other Stimulants12-Benzodiazapines13-Other Tranquilizers14-Barbiturates15-Other Sed/Hypnotic16-Inhalants17-OTC meds18-Other19-Tobacco99 unknown / Years / 1 - Oral2 - Smoking3 - Inhalation4 - Injection5 - Other99 unknown / 0-Not used past month1-Used 1 to 3x past month2-Used 1 to 2x per week3-Used 3 to 6x per week4-Daily use99 unknown / Per daywkmo.yr.
ASAM Patient Placement Criteria Adult/Adolescent
(See ASAM criteria for placement considerations) / CURRENT(C) and PREVIOUS (P) TREATMENT)
Service / Current / Previous / Comments
Case Management / C P
Mental Health Outpatient / C P
Mental Health Inpatient / C P
Substance Abuse Outpatient / C P
Detox / C P
Substance Abuse Inpatient / C P
Other / C P
I / II.1/5 / III.1 / III.3 / III.5 / III.7 / IV
I. Withdrawal/Intoxication
II. Medical Complication
III. Behavioral/Emotional Cognitive Complication
IV. Readiness for Change
V. Relapse/Continued use or problem potential
VI. Recovery Environment
Placement Recommendation:
MEDICAL: Current Primary Care Physician Name: Signed Release to Primary Care Physician? Yes No
Medically- Compliant Non-compliant Comments:
CURRENT MEDICATIONS / Current Regimen / # of months / CURRENT MEDICATIONS / Current Regimen / # of months
Adderall / amphetamine +Concerta / methylphenidate+Dexedrine / dextroamphetamineDextrostatDexedrine SpansulesMetadate / methylphenidate+MethadoneMethylinRitalin / methylphenidateRitalin SRStrattera / Atomoxetine 0.10.51251015202530405075100125150200250300350400450500 mg / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1 / Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1
Anafranil / clomipramineAventyl /Celexa / citalopramDesipramineDesyrel / trazadoneEffexor / venflexamineElavil / amitryptalineLudiomil / maprotilineLuvox / fluvoxamineNardil (MAO inhibitor)Norpramine / desipraminePamelor / tranylcyprominePaxil / paroxetinePaxil SRParnate / tranylcypromine** MAOIProzac / fluoxetineSinequan / sertralineSurmontil / trimipramineVivactil / protriptyleneWellbutrin / bupropionWellbutrin SRZoloft / sertralineZybanTofranil / imipramine 0.10.51251015202530405075100125150200250300350400450500 mg / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1 / Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1
Ambien / zolpidemAtivan / lorazepamBuspar / BuspironeCialisKlonopin / clonazapamLevitraOxycodone / OxycontinPercosetRestoril / Vistaril / Valium / diazepamViagraXanax / alprazolam 0.10.51251015202530405075100125150200250300350400450500 mg / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1 / Other: / prn1x per day1 q.a.m1 q. noon1 q.h.s.1, 2x per day1 b.i.d1 t.i.d.1 q.i.d1 q.a.m. and 2 q.p.m.2 q.a.m. and 1 q.p.m2, 2x per day2 b.i.d2 t.i.d2 q.i.d.i.m. per weeki.m. per 2 weeksi.m. per 3 weeksi.m. per 4 wk / month / <1 >1
Allergies:
Reason for Admission, Continued Stay or other comments:

Request for Service

Service Description & Code / Funding Source / Frequency / Duration / Start Date / End Date / Provider / UM ACTION / Units Approved
Approved Pended
Denied-Pt Denied-All
Approved Pended
Denied-Pt Denied-All
Approved Pended
Denied-Pt Denied-All
Clinician Signature: / Requesting Provider: / Date:

SandhillsCenter Care Management / Utilization Management Use Only

UM COMMENTS:
Utilization Management Care Coordinator:Emily Godfrey 704-743-2102David Hollar 704-743-2117Pamela Caviness Rankin 704-743-2107Tracy Sherrill 704-743-2108Chuck Spears 704-743-2103Jane Austin 704-743-2110Melissa Covert 704-743-2101Janet Garvin 704-743-2109Andria Misenheimer 704-743-2114 Date:
Sandhills Center Care Management / Utilization Management #: 1-800-241-1073 Fax#: 336-389-6127
**Submission does not automatically constitute authorizations. All treatment is subject to medical necessity determination and based on beneficiary eligibility

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SHC – 09/2012