SUD UM Submission Form
***Please fill out all sections of this form. Type N/A if not applicable.
Type of RequestChoose an item.
Client Name:
FirstClick here to enter text.
Last Click here to enter text.
Date of Birth Choose Date
Parent/Guardian Name (if minor):
First Click here to enter text.
Last Click here to enter text.
Medicaid (Active)Choose an item.
Medicaid ID# (if applicable)Click here to enter text.
UWITS IDClick here to enter text.
Agency Client ID (if applicable)Click here to enter text.
PopulationChoose an item.
Funding Source RequestedChoose an item.
Date of AdmissionChoose Date
Current Level of Care Choose an item.
Start DateChoose Date
New Level of Care(if applicable)Choose an item.
Start DateChoose Date
Treating AgencyClick here to enter text.
Facility Bed Number (Res only)Choose an item.
InsuranceChoose an item.
If Private Insurance, Co. nameClick here to enter text.
Employment StatusChoose an item.
Monthly incomeChoose an item.
Current Medications and Dosage
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Diagnosis/Diagnoses
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If submitting a Medicaid authorization request for the client’s child(ren), please include the following: name, date of birth, Medicaid ID# and start date.
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Statement of what client would like to see happen in terms of treatment and proposed services: (Initial Review Only)
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ASAM narrative in the encounter attached to the treatment plan that reviews the progress towards established treatment goals, the appropriateness of services being provided, updates strengths and barriers in each ASAM dimension, and provides any other relevant information that helps to define medical necessity:
D1: Acute Intoxication and/or Withdrawal Potential
Risk RatingChoose an item.
Level of CareChoose an item.
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D2: Biomedical Conditions and Complications
Risk RatingChoose an item.
Level of CareChoose an item.
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D3: Emotional, Behavioral, or Cognitive Conditions and Complications
Risk RatingChoose an item.
Level of CareChoose an item.
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D4: Readiness to Change
Risk RatingChoose an item.
Level of CareChoose an item.
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D5: (If Initial Review, document substance use history) Relapse, Continued Use Potential
Risk RatingChoose an item.
Level of CareChoose an item.
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D6: Recovery/Living Environment
Risk RatingChoose an item.
Level of CareChoose an item.
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Discharge criteria for current LOC: (what goals will the client have met to be eligible for discharge/transfer?)
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Discharge plan for current LOC: (recommended follow-up care)
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Estimated length of stay for current LOC: Click here to enter text.
Signature and Licensure Click here to enter text.