933144 04/2020
(_____)
(_____)
Service Code
# Units/Days
requested
Service Start
Date
Service End
Date
1.
2.
3.
Indentifying Data
Request Submission Date:
Last:First: MI:
Customer ID:
Gender:
Date of Birth:
Male Female
Request Authorizations
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health of the patient or the patient's ability to regain maximum function.
Clinical justification for expedited review:
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Medicare Advantage
Inpatient Treatment Request
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Request Type
Standard Expedited (Check one): (additional information required below):
Provider Attestation (Expedited Requests Only)
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CLEAR FORM
933144 04/2020
Diagnosis ICD 10 Codes
Psychotropic Medications
Medication
Changed
since last
report?
Dosage Frequency Adherent?
Previous
or
current?
Clinical Narrative
Provide information to support this request: symptoms, risk factors, social history, substance abuse history, etc.
933144 04/2020
Co-occurring Medical Conditions
Treatment History
All levels of care
Level of Care
Date of last
treatment
Level of Care
Date of last
treatment
# of distinct
episodes/
sessions
Inpatient
psychiatric
Inpatient
Substance Use
Disorder
Partial
Hospitalization
(PHP)
Inpatient Outpatient
(IOP)
Outpatient psych
(individual or group)
Outpatient substance
abuse (individual or
group)
# of distinct
episodes/
sessions
Treatment Goals and Outcomes
Complete fields below and/or attach current treatment plan
Treatment Goals
1.
2.
3.
Objective outcome criteria by which goal will be measured:
1.
2.
3.
4.
933144 04/2020
Expected Outcome and Prognosis (check all that apply)
Return to normal functioning
Expected improvement, anticipated less than baseline functioning
Relieve acute symptoms, return to baseline functioning
Maintain current status, prevent deterioration
Discharge/Termination Plan (include estimated discharge date)
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