Fillable Complex Case Review Mercy Care RBHA Medical Management (Mercy Care)

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Complex Case Review Mercy Care RBHA Medical Management (Mercy Care)

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Revised: 07/01/2018
Complex Case Review
Provider – Please email Complex Case Review form to:
Mercy Care RBHA Medical Management at: ComplexCase@MercyCareAZ.org
Priority Status:
Routine Immediate T19
Non-T19
Date:
Member Name:
DOB:
Behavioral Health Category:
SMI GMH/SA Child
AHCCCS ID:
Other Insurance:
Guardian or Advocate (if applicable):
DDD Case Manager (if applicable):
Member’s Current Location
Provider/Agency:
Phone:
Fax:
Requesting Provider Contact Information
Provider / Clinic:
Name:
Title:
Email:
Phone:
Member’s Primary Behavioral Health Provider Contact Information
Provider / Clinic:
Phone:
BHMP Name:
Phone:
Medical Provider Name:
Phone:
CD Name:
Email:
CC Name:
Email:
CM Name:
Email:
Reason for request for complex case review (include services requested, type of request, applicable dates, etc.):
Complex Case Review
Additional Comments:
Revised: 07/01/2018
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Complex Case Review Mercy Care RBHA Medical Management (Mercy Care)

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Completed 31 July 2021

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