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

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Intensive In-Home Therapy Request Form 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: 6/15/11 Health Management Fax: (715) 852-5755 GHC11091 Page 2 of 2
Neuro/Psychological Testing Request Form Member Name: _______________________________________ Member ID:_____________ DOB: _____________ *Please attach a copy of the psychological intake and fax to: (715) 852-5755 Diagnosis Level of Care Has the patient had previous testing? Axis I: ___________________ Inpatient Yes No Axis II: ___________________ PHP If yes, when? _____/_____/_____ Axis III:___________________ IOP Testing Requested: Axis IV:___________________ Outpatient Psychological Neuropsychological Axis V: ____________________ Projected Date of Service: ____________ What specific questions will be answered by the evaluation? 1.____________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ Describe how the evaluation will help to implement the treatment plan: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Describe what other strategies/treatments have failed: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Specify the proposed measures and rationale for use: Measure Name:________________________________________________ CPT Code: _________ Hours: _______ Rationale:_____________________________________________________________________________________ Measure Name:________________________________________________ CPT Code: _________ Hours: _______ Rationale:_____________________________________________________________________________________ Measure Name:________________________________________________ CPT Code: _________ Hours: _______ Rationale:_____________________________________________________________________________________ Measure Name:________________________________________________ CPT Code: _________ Hours: _______ Rationale:_____________________________________________________________________________________ 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 GHC11023
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Page 67 and 68: Out-of-Network Referral Event Autho
Page 69 and 70: Therapy Request Form Please indicat
Page 71 and 72: Speech Therapy Request Form Patient
Page 73 and 74: Autism Treatment Services Request F
Page 75 and 76: Discharge Information Request Form
Page 77: Intensive In-Home Therapy Request F
Page 81 and 82: Partial Hospitalization Treatment S
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BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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