BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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Service Event Authorization Request Form Patient’s Name: Referring Provider: Name/Clinic DOB: _______________ ID#__________________ Tax ID: ______________ Fax#: ________________ Refer to Provider: Name/Specialty/Clinic Phone #: ___________________________ Tax ID: ______________ Fax#: ________________ Diagnosis: ICD-9: ICD-9 Procedure Code requesting: CPT Procedure Code requesting: Description: Description: Please provide clinical information for justification of need for service. Place of Service: Projected Date of Service: Projected End Date of Service: Please select one: Anticipate Outpatient service only. Anticipate Observations stay for _____ hours. Anticipate Inpatient Admission for _____ days. Please indicate if any of the following is suspected to be a cause of the indicated need for the service: MVA Liability Workers’ Compensation Indicate if this is an emergent request ~ Please note ~ If in the case of an emergent medical need for a service event authorized service, a service event request with clinical justification of the emergent need must be faxed to the Health Management Department as soon as possible before the services are performed. Please indicate on your request the need for an emergent review. Provider Contact Name Phone # Date Please refer to the Provider Manual for specific information regarding the need for service event authorizations. Privacy and Confidentiality: The information within this fax message is intended for the recipient(s) only. If you have received this fax in error, please contact us at (715) 552-4300 and destroy this document received. State and Federal Law prohibits any unauthorized use of this information. Thank you for your cooperation. Revised: 3/15/12 Health Management Fax: (715) 552-7202 GHC11039
Speech Therapy Request Form Patient’s Name: DOB: ________________ ID#_____________________ Ordering Physician: Clinic: ________________________________________ Therapy Provider: Name/Specialty/Clinic Phone #: ___________________________ Tax ID: _______________ Fax#:___________________ Diagnosis: ICD-9: Date of Initial Eval: Is this a Worker’s Comp or accident case? Yes No Dates of service requested: __________________________________________________________ Number of visits requested: __________________________________________________________ PLEASE SEND EVALUATION FOR FIRST REQUEST ONLY. ADDITIONAL REQUESTS WILL NEED ONLY THE MOST RECENT VISIT NOTE. Provider Contact Name Phone # Date A Speech Therapy Evaluation will be required after the initial evaluation. If additional visits are needed, authorization is required prior to continuing. Services must be prescribed and monitored by a Primary Care Physician or Specialty Physician to be considered a covered benefit. Revised: 3/15/12 Health Management Fax: (715) 552-7202 GHC11043
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Page 73 and 74: Autism Treatment Services Request F
Page 75 and 76: Discharge Information Request Form
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Page 79 and 80: Neuro/Psychological Testing Request
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BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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