601 Potrero Grande Drive, Monterey Park, CA 91755
BHT Telephone: (888) 297-1325
BHT Direct FAX Line: (844) 283-3298
TREATMENT AUTHORIZATION REQUEST
URGENT
ROUTINE RETROACTIVE
I. PATIENT INFORMATION PRIMARY LANGUAGE SPOKEN:
Require Interpreter: No Yes American Sign Language
Member Name: DOB: GENDER: F M
Member Address: City: ZIP:
Phone: Member ID: Medicare Medi-Cal Cal MediConnect
II. REFER TO INFORMATION
Date of Request: Provider Name: Specialty:
Provider Address: Phone: Fax:
Facility Name: Phone: Fax:
III. SERVICE(S) REQUESTED
Initial Consult FU Visit(s): Home Health Social Services DME
Diagnostic Evaluation for Autism Spectrum Disorder Psychological Assessment for:
Applied Behavioral Analysis (If checked, please submit the BSCPHP ABA Referral Form to establish medical
necessity)
Inpatient Admission Outpatient Procedure(s) Other:
Diagnosis: ICD 10 Code(s):
Service(s)/Procedure(s): CPT Code(s):
Reason for Request:
Prior Treatment and Results:
Relevant Labs/X-Rays, etc:
Health Education (Specify):
Requesting Physician’s Name (PLEASE PRINT):
Physician’s Signature: License No.:
Physician’s Phone: Fax:
Accident: YES NO Where Occurred: Home Work Auto Other:
TO BE COMPLETED BY BSCPHP ONLY
UM Decision Status: APPROVED MODIFIED DEFERRED DENIAL
AUTH#: DATE APPROVED: EXPIRATION DATE:
COMMENTS:
Reviewer’s Name: Signature: Date:
Member Eligibility as of: PCP Provider ID:
IPA RESPONSIBILITY MBHO RESPONSIBILITY DATE FAXED TO IPA/MBHO:
Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association
THIS REFERRAL DOES NOT GUARANTEE ELIGIBILITY. CHECK ELIGIBILITY PRIOR TO RENDERING SERVICE.
Payment will NOT be made for unauthorized services. All lab and x-rays must be ordered/performed by
contracting providers (contact Blue Shield of California Promise Health Plan U.M. Department at
above number if unsure). Specialist reports must be sent to PCP promptly.
