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

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Outpatient Treatment Services Request Form Member Name: ____________________________________ Member ID:_____________ DOB: _____________ *Please attach clinical information/progress notes, current medications, and therapeutic goals and fax to: (715) 852-5755 The initial six visits of the calendar year do not require prior authorization. Diagnosis Patient Participation: Poor Fair Good Axis I: ___________________ Axis II: ___________________ Date of First Session: __/__/__ Axis III:___________________ Number of Sessions to Date: ________ Axis IV:___________________ Estimated Number of Visits until Termination: _____ Axis V: ____________________ Estimated or Actual Discharge Date: __/__/__ Type of Service: Mental Health AODA Psychiatry Individual Therapy Frequency:____________ # Visits Requested:____________ Family Therapy Frequency: ___________ # Visits Requested:____________ Group Therapy Frequency: ___________ # Visits Requested:____________ Authorization Period to Begin: ___/___/___ Brief Summary of Current Clinical Status: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Criteria for Termination: __________________________________________________________________________________________ __________________________________________________________________________________________ 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 GHC11024
Partial Hospitalization Treatment Services Request Form Member Name: _______________________________________ Member ID:_____________ DOB: _____________ *Please attach clinical information including medications and fax to: (715) 852-5755 Diagnosis Patient Participation: Poor Fair Good Axis I: ___________________ Axis II: ________________ Type of Service: Axis III:___________________ Mental Health Axis IV:___________________ AODA Axis V: ____________________ Psychiatry Date of Admission __/__/__ Estimated Length of Stay: _________ Brief Summary of Current Clinical Status: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Brief explanation as to why this level of care is appropriate: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Past Levels of Care Attempted: Outpatient? If yes, when and where: ________________________________________________________________ Inpatient? If yes, when and where: _________________________________________________________________ Please describe why past levels of care attempted will not meet patient needs at this time: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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 GHC11025
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