This notification is to be completed (typed) by the current treating clinician or case manager if RBHA funding for a behavioral health admission to one of the above facilities is being requested. Send the completed form by secure fax to 1-866-601-0111 within three days after the member’s admission to one of the above facilities.
Date of Notice:
Selection / Facility/Service / Initial Authorization(no Prior Auth required) / Concurrent Review
(submit Form 10-1-8 at least 7 days before last covered day)
☐ / AIC / 14 days / At 14 days, 30 day max stay
☐ / BIP / 10 days / None, 10 day max stay
☐ / BHRF for DTAP / 30 days / Every 30 days, 90 day max stay
☐ / BHRF for SUD / 14 days / Every 14 days
Member’s Name:
PM Form 3.14.5 Page 2 of 2
Revised 03/14/14
AIC=Acute Intervention Center
BIP=Brief Intervention Center
BHRF=Behavioral Health Residential Facility (formerly known as TGH or L3GH)
DTAP=Drug Treatment Alternative to Prison
SUD=Substance Use Disorder
Member’s Name:
PM Form 3.14.5 Page 2 of 2
Revised 03/14/14
For BHRF for SUD admissions, is the member in a Priority Population?: ☐Yes ☐No
If yes: ☐Female with dependent children ☐Intravenous drug user ☐Pregnant female
Member’s name: Age: DOB: Gender:
SSN: CIS#: ____ AHCCCS ID#:
Mailing address: City/State/Zip: ______
Street address: ______City/State/Zip: ___
Member’s primary language: ☐English ☐Spanish ☐Other (specify):
☐COT for DUI ☐COT for DV ☐COT for other: ______☐Voluntary status
Behavioral Health Category: ☐C/A ☐GMH ☐SMI ☐SA
Funding source: ☐T19 ☐T21 ☐SABG ☐Other: _
Primary ICD-10 diagnosis:
Facility name: ______City: Date of admission: ______
Intake agency:
Primary contact at intake agency: Phone #: Ext:
Contact’s e-mail address:
If applicable:
Legal guardian: Phone/Extension #: Fax #:
Mailing address: City/State/Zip:
Legal guardian’s primary language: ☐English ☐Spanish ☐Other (specify):
Member’s Name:
PM Form 3.14.5 Page 2 of 2
Revised 03/14/14