Fillable Outpatient-request-form-behavioral-health Outpatient Treatment Referral Form

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Outpatient-request-form-behavioral-health Outpatient Treatment Referral Form

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The Outpatient-request-form-behavioral-health Outpatient Treatment Referral Form form is 4 pages long and contains:

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  • 4 check-boxes
  • 102 other fields

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File type: PDF

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933152 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
By signing below, I certify that applying the standard review timeframe for this service request may seriously jeopardize the life or
health of the patient or the patient's ability to regain maximum function.
Clinical justification for expedited review:
Medicare Advantage
Outpatient Treatment Request
Fax completed form to: 866-949-4846 Fill out completely to avoid delays
Request Type
Standard Expedited (Check one): (additional information required below):
Provider Attestation (Expedited Requests Only)
Physician/clinician name: Signature:
Address:
City: State: Zip:
INT_20_85391_C
4.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna
HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis,
Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name,
logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
© 2020 Cigna. Some content may be provided under license.
CLEAR FORM
933152 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 use history, etc.
Provider Information
(_____)
(_____)
Check one:
Member agreed to release of information to their PCP and/or other treating providers dated .
Member has been informed for release of information and has declined
Other BH Provider(s):
Name (program, facility or provider): NPI #:
Phone:
Fax:
(_____)
To whom should the authorization determination be sent? Name:
(_____)
Phone:
Fax:
933152 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
use (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.
933152 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)
Fax completed form to: 866-949-4846
Fill out completely to avoid delays
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Outpatient-request-form-behavioral-health Outpatient Treatment Referral Form

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Completed 2 July 2020

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