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

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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 67 and 68: Out-of-Network Referral Event Autho
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Page 73: Autism Treatment Services Request F
Page 77 and 78: Intensive In-Home Therapy Request F
Page 79 and 80: Neuro/Psychological Testing Request
Page 81 and 82: Partial Hospitalization Treatment S
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BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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