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IDENTIFYING DATA
PATIENT’S NAME: MEDICAID #: DOB:
PROVIDER INFORMATION
PROVIDER NAME: TAX ID NUMBER:
PHONE #: FAX #:
PCP NPI #:
DSM-IV TR DIAGNOSIS
AXIS I: AXIS II: AXIS III:
Moderate
Chronic
Chronic
Severe
Severe
Acute
Acute
Mild
Mild
Symptoms/Problems
JOB/SCHOOL:
HOUSING:
TREATMENT GOALS:
1.
2.
3.
RISK HISTORY:
Explain any significant history of suicidal, homicidal, impulse control or any behavior that may impact patient’s level of functioning:
REQUESTED AUTHORIZATION:
Procedure Code: Number of Units: Frequency: Units Approved:
Procedure Code: Number of Units: Frequency: Units Approved:
Procedure Code: Number of Units: Frequency: Units Approved:
Procedure Code: Number of Units: Frequency: Units Approved:
❑ Approved – Auth #:
PROVIDER’S SIGNATURE: DATE:
Disclaimer: Authorization indicates that AMERIGROUP determined that medical necessity has been met for the requested service(s) but does not
guarantee payment. Payment is contingent upon the eligibility and benefit limitations at the time services are rendered.