Fax Completed Form to TBH at 541-984-5692

Fax completed form to TBH at 541-984-5692

☐ICTS☐PDTS ☐PRTS ☐SUBACUTE☐ACT

Today’sdate: Click here to enter a date.
With this request you MUST submit: ☐BH Assessment (written within the past year)
☐Service Plan (required to be updated to reflect
services necessary to complete authorization request)

MemberName: Click here to entername.

/

DOB: Click here to enter DOB.

Member ID Number:

Member Phone Number:

Parent/Guardian Name:

Requesting Practitioner:

Requesting Agency:

Prescribing Practitioner:

QMHA/Skill Builder (ICTS):

Wraparound Involvement:

Trillium Authorization Number(for concurrent review):

Current diagnosis for concurrent review (include ICD codes and names):
*limited to 360 characters

Current medications (include dose and frequency): *limited to 360 characters

Pertinent medication changes since last review: *limited to 360 characters

Symptoms in past 90 days (Describe behaviors, thoughts, feelings AND how each impacts functioning in daily life. Do not list diagnoses.)
*limited to 420 characters / Frequency/Duration / Progress
/ Frequency 1: Choose an item.
Frequency 2: Choose an item.
Duration: Choose an item. / ☐Improving
☐Same
☐Regressing
/ Frequency 1: Choose an item.
Frequency 2: Choose an item.
Duration: Choose an item. / ☐Improving
☐Same
☐Regressing
/ Frequency 1: Choose an item.
Frequency 2: Choose an item.
Duration: Choose an item. / ☐Improving
☐Same
☐Regressing
/ Frequency 1: Choose an item.
Frequency 2: Choose an item.
Duration: Choose an item. / ☐Improving
☐Same
☐Regressing

Domains impacting or impacted by (if checked, include explanation):
*limited to 320 characters

☐Individual functioning/ADL (activities of daily living):

☐Relational/family system:

☐Educational/occupational:

☐Housing/basic needs (include DD or SDS):

☐Substance use:

☐Social (include level of support):

☐Legal (include DHS/DYS involvement):

☐Medical/Physical health:

☐Recent hospitalizations, crisis interventions, and/or ED use:

☐Safety:

☐Other:

Clinical justification: Describe the last 6months of services that the member has received from all behavioral health providers and any coordination of care provided amongst your organization and other behavioral health providers. *limited to 1550 characters

Describe your reasoning for the services you will be providing to address the client’s current diagnosis, symptoms, domains, and the expected outcomes of those services.
*limited to 1550 characters

Services requested (for concurrent review only) – For an initial prior authorization request
DO NOT complete the grid below since the CPT codes/units have been requested on the
initial electronic or paper PA.

For a concurrent PA request, complete the grid below. A concurrent PA request is when there is an approved authorization and the client has exhausted all approved CPT codes/unites and the provider is requesting additional units to be added within the PA date range.

CPT (billing) CODE
(click on drop down arrow) / Number of Units

MCA_ZZ33V3NR Effective 10/26/2015 rvsd6-1-2016