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please notify 1-844-866-WEST (9378) at once and destroy the documents and any copies you have made.
Authorizations and Referrals • PO Box 9108 • Virginia Beach, VA 23450-9108
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. • HF0917x058 (03/18)
V3.0 Last Updated 03/16/2018 Page 1 of 1 BH Rqst Extension
I attest the information provided is true and accurate to the best of my knowledge. I understand Health Net Federal Services, LLC
or designee may perform a routine audit and request the medical documentation to verify the accuracy of the information reported
on this form.
Attending Provider’s Name and Title: _________________________________________________________________________________
Attending Provider’s Phone: _________________________________________________________________________________________
TIN: _________________________________________________
Signature: _______________________________________________________________ Date: ______________________________
Request for Extension of Mental Health Services
Dear Provider,
In order to request an extension of authorized mental health services, please complete the fields below and submit this form
along with the required documentation online at www.tricare-west.com. Health Net Federal Services, LLC (HNFS) will review
your request once received. Medical necessity review is based on the information submitted. If incomplete, the HNFS medical
director will make the final determination.
Please note, services must be medically and psychologically necessary for the level of care requested and that care may
not be custodial in nature. There must be evidence of a coherent and specific plan for assessment, intervention and
reassessment that reasonably can be accomplished within the time frame of the additional days of coverage requested.
The authorization for services approved ended on ________________ and an extension of services is requested.
Case Reference Number: _______________________________
Beneficiary Information
______________________
Beneficiary’s Full Name: ____________________________________________ Sponsor’s SSN/DBN: ______-______-________
Date of Birth: ____________________
Facility Information
__________________
Facility Name: ________________________________________________________________________________________________
Telephone: ________________________________________________ Fax: ____________________________________________
Clinical Justification
___________________
Please attach following (all are required):
• summary of course of treatment and progress towards treatment goals
• current length of stay (LOS), estimated total LOS and days requested
• goals anticipated to be reached within the requested extension period
• current treatment plan
• treating provider progress notes for last five days
Provider Attestation
___________________
A Wholly-Owned Subsidiary of Centene Corporation
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signature
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