Member: ______ID#______

Community Based Services Request Form
Fax: 312-324-0644|UM Department Phone: 888-704-4584
*** PLEASE TYPE or WRITE LEGIBLY OR REQUEST WILL BE RETURNED AS UNABLE TO PROCESS ***
Member: ______ Provider Name: ______Provider Telephone: ______
Member DOB: ______Provider Group/Clinic: ______Provider Fax: ______
Member ID:______Service Address: ______City/State/Zip: ______
Provider ID/NPI: ______Tax ID# ______
Start Date for this authorization request: ______
Codes that do not require authorization:
H0002 / LOCUS Assessment
H2011 / Crisis Intervention
H0031 / Mental Health Assessment
Please indicate the level of care requested:
ACT (Assertive Community Treatment)- up to 6 month auth range / CST (Community Support Team)- up to 6 month auth range / Community Support- Individual/Group
Up to 6 month auth range
Crisis Residential Services- must request within 72hrs of admission- up to 14 days / CSR (Community Support Residential)- up to 6 month auth range / Adult Outpatient
Up to 6 month auth range
Child/Adolescent Outpatient
Up to 6 month auth range / Supported Housing
Describe Type: / Other:
Yes No Is this a request for a new level of care?
If yes, please attach summary of initial comprehensive assessment or updated comprehensive assessment indicating a new level of care is clinically appropriate.
Yes No Is this an extension of the current level of care?
If yes, please provide the date services initiated:
If yes, please attach summary of updated LOCUS assessment and summary of progress toward treatment plan goals.
Diagnosis: primary ICD-10 or DSM-5 and other applicable co-occurring diagnoses- please provide code and description
Primary:
2nd:
3rd:
Please check box if present:
Inability to consistently perform ADLs / High use of psychiatric emergency or crisis services / At risk of requiring more restrictive living situation without intensive community services
Inability to maintain stable housing / Persistent severe major symptoms (psychotic, SI, HI, etc) / Primary diagnosis of personality disorder, SUD, or mental retardation
Inability to maintain consistent employment / Co-existing SUD / Coordination of care with other providers, ex PCP, specialists, IP, AOT, community support
Inability to succeed in traditional office-based services / Current risk or recent history of criminal justice involvement / Results of initial comprehensive assessment or assessment updated every 6 months
High use of IP hospitalizations / Demonstrated progress toward treatment plan goals / Adjustment of treatment plan goals due to lack of progress toward initial goals
Psychopharmacological intervention initiated/evaluated / Other: / Other:
Risk Assessment (please check NO if not present- if checked, please provide additional information)
Yes No / SUICIDAL RISK: / Yes No / HOMICIDAL RISK: / Yes No / ABUSE RISK:
Yes / Ideation / Yes / Ideation / Yes / Verbal
Yes / Intent / Yes / Intent / Yes / Emotional
Yes / Plan / Yes / Plan / Yes / Physical
Yes / Means / Yes / Means / Yes / Sexual
Yes / Attempt / Yes / Attempt / Yes / Neglect
Medication Name/Dosage/Frequency: Not applicable:
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2.
3.
4.

Requested Codes and Amount Requested:

H0004 Individual/Group Therapy- Units: / T1013- Oral Interpretation & Sign Language- Units: / 90791 Initial Psychiatric Evaluation
H0039- ACT
Units: / T1016 Case Management
Units: / 90792 Initial Psychiatric Evaluation with Med Management
H2010- Med Monitoring (Nurse) Units: / T1502 Psychotropic Medication Administration- Units: / 99212 Medication Monitoring (MD)
Visits:
H2015- Community Support
Units: / Other: / 99213 Medication Monitoring (MD)
Visits:
H0032- Treatment Plan Development, Review, or
Modification
Units: / Please specify 992 Code Requested:
992_ _ + 90834
Visits: / 99214 Medication Monitoring (MD)
Visits:
H0034 Psychotropic Medication Training
Units: / Please specify 992 Code:
992_ _ + 90836
Visits: / Please specify 992 Code:
992_ _+ 90838
Visits:
Other: / Other: / Other:

Printed: Clinician Name and Credential(s):______

Clinician Signature and Date: ______

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