BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ... BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
Authorizations are given for a 3 month time period; please list number of anticipated sessions accordingly: Level: Intensive __Sessions for social group __Sessions for in home __Sessions of parent training __Sessions of 1:1 ABA __Sessions of sibling group Level: Non-intensive __Sessions for social group __Sessions for in home __Sessions of parent training __Sessions of 1:1 ABA __Sessions of sibling group Provider Name:_______________________ Phone: _________________ Fax: ____________ Facility Name: ________________________Address: _________________________________ Tax ID: _____________________________ I certify that I am the provider who will be delivering the services listed above and that the information contained herein is true and correct to the best of my knowledge. Provider Signature _________________________________________ Date_______________ The submission of supporting clinical documentation/plan of care is required with this form Fax completed form to: (715) 852-5755 Group Health Cooperative Health Management Phone: (800) 218-1745 Revised: 3/24/11 Health Management Fax: (715) 852-5755 GHC11020 Page 2 of 2
Discharge Information Request Form Member Name: ____________________ Member ID:_____________ DOB: _____________ Provider:___________________________________________________________________ Admission Date:___/___/___ Discharge Date: ___/___/___ Discharged to: ______________ *Please attach discharge summary and fax to: (715) 852-5755 Discharge Medications: Follow-up Appointments: Other Pertinent Information: The submission of supporting clinical documentation/plan of care is required with this form Fax completed form to: (715) 852-5755 Group Health Cooperative Health Management Phone: (800) 218-1745 Revised: 3/24/11 Health Management Fax: (715) 852-5755
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- Page 73: Autism Treatment Services Request F
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Authorizations are given for a 3 month time period; please list number of anticipated<br />
sessions accordingly:<br />
Level: Intensive<br />
__Sessions for social group<br />
__Sessions for in home<br />
__Sessions of parent training<br />
__Sessions of 1:1 ABA<br />
__Sessions of sibling group<br />
Level: Non-intensive<br />
__Sessions for social group<br />
__Sessions for in home<br />
__Sessions of parent training<br />
__Sessions of 1:1 ABA<br />
__Sessions of sibling group<br />
<strong>Provider</strong> Name:_______________________ Phone: _________________ Fax: ____________<br />
Facility Name: ________________________Address: _________________________________<br />
Tax ID: _____________________________<br />
I certify that I am the provider who will be delivering the services listed above and that the information<br />
contained herein is true and correct to the best of my knowledge.<br />
<strong>Provider</strong> Signature _________________________________________ Date_______________<br />
The submission of supporting clinical documentation/plan of care is required with this form<br />
Fax completed form to: (715) 852-5755 <strong>Group</strong> <strong>Health</strong> Cooperative <strong>Health</strong> Management Phone: (800) 218-1745<br />
Revised: 3/24/11 <strong>Health</strong> Management Fax: (715) 852-5755<br />
GHC11020 Page 2 of 2
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