P.O. BOX 11033 ORANGE, CA 92856 Phone: 855-877-3885
Behavioral Health-Authorization Request Form (BH-ARF)
ROUTINE Behavioral Health Fax: 714-571-2462
*** IN ORDER TO PROCESS YOUR REQUEST, BH-ARF MUST BE COMPLETE AND LEGIBLE ***
PROVIDER: Authorization does not guarantee payment. ELIGIBILITY must be verified at the time services are
rendered.
MEMBER INFORMATION
Member Name (Last, First): Sex: M F Other:
Age: DOB: Client Index # (CIN): ICD-10 Dx:
Mailing Address Phone:
Program (select one only): Medi-Cal OneCare OneCare Connect
REFERRING PROVIDER INFORMATION
RENDERING PROVIDER INFORMATION
(If different from referring provider)
Name: Name:
NPI: Medi-Cal ID: NPI: Medi-Cal ID:
TIN: Phone: Fax: TIN: Phone: Fax:
Address: Address:
Office Contact:
Office Contact:
Provider’s Signature:
AUTHORIZATION REQUEST
URGENT REQUEST Fax to 714-481-6453. ***Definition: “Urgent” is ONLY when normal time frame for authorization will be
detrimental to patient’s life or health, jeopardize patient’s ability to regain maximum function, or result in loss of life, limb or other major
bodily function. Urgent requests are addressed within 72 hours.***
List ALL procedures requested, along with the appropriate CPT/HCPCS. Supporting documentation to include:
• Psychological Testing Request Form (For psych testing only)
• Clinical records to support request
REQUESTED PROCEDURES CODE (CPT or HCPCS) UNITS AND
DURATION
07-23-2020
click to sign
signature
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