SUBMIT TO
Utilization Management Department
Phone: 1-855-766-1497 Fax: 1-877.-725-7751
Tax ID #: _____________________________________________________
REQUESTED AUTHORIZATION FOR ECT
Please indicate type(s) of service provided by YOU and the frequency.
Total sessions requested: _________________________________________
Type Bilateral: _____________ Unilateral: ____________________
Frequency: ____________________________________________________
Date rst ECT: ___________________ Date last ECT: _________________
Est. # of ECTs to complete treatment: _______________________________
Requested start date for authorization: ______________________________
LAST ECT INFO
Length: ___________________ Length of convulsion:_________________
PCP COMMUNICATION
Has information been shared with the PCP regarding behavioral health pro-
vider contact information, date of initial visit, presenting problem, diagnosis,
and medications prescribed (if applicable)?
PCP communication completed via: Phone
Fax
Mail
Member refused by: _____________________________________________
Coordination of care with other behavioral health providers? _____________
Has informed consent been obtained from patient/guardian? _____________
Date of most recent psychiatric evaluation: ____________________________
Date of most recent physical examination and indication of an anesthesiology
consult was completed: ___________________________________________
ELECTROCONVULSIVE THERAPY (ECT) AUTORIZATION REQUEST FORM
Please print clearly – incomplete or illegible forms will delay processing.
DEMOGRAPHICS
Patient Name:
Date of Birth: ___________________________________________________
__________________________________________________
Social Security #: ________________________________________________
Patient ID:
_____________________________________________________
Last Auth #: ____________________________________________________
PREVIOUS BH/SUD TREATMENT
None or OP MH SUD and/or IP MH SUD
List names and dates, include hospitalizations: _______________________
_____________________________________________________________
Substance Abuse None By History and/or
Current/Active
Substance(s) used, amount, frequency, and last used: _________________
_____________________________________________________________
PROVIDER INFORMATION
Provider Name (print): __________________________________________
Hospital where ECT will be performed: ______________________________
Professional Credential:
MD
PhD
Other __________
Physical Address: ______________________________________________
Phone #: ____________________________ Fax #: __________________
TPI/NPI #: ____________________________________________________
CURRENT RISK/LETHALITY
Suicidal
Homicidal
Assault/Violent
Behavior
Psychotic
Symptoms
*3, 4, or 5 please describe what safety precautions are in place
_____________________________________________________________
_____________________________________________________________
1 NONE 2 LOW 3 MOD* 4 HIGH* 5 EXTREME*
CURRENT ICD DIAGNOSIS
Primary: _____________________________________________________
R/O: ____________________________ R/O: _______________________
Secondary: ___________________________________________________
Teritary: ______________________________________________________
Additional: ____________________________________________________
Additional: ____________________________________________________
ALLWELL FROM ABSOLUTE TOTAL CARE | PAGE 1
