Get Mental Health Servicespreauth Form.doc - Mchd-tx

Filling out the Mental Health Services Preauthorization Request Form is an essential step in ensuring that individuals receive the necessary mental health services. This guide provides a clear and step-by-step approach to completing the form accurately and efficiently.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to obtain the Mental Health Services Preauthorization Form and open it in your preferred editor.
2. Enter the patient's or client’s full name and date of birth in the designated fields.
3. Provide the patient's ID number and group number as required.
4. Indicate the patient's gender by selecting either 'Male' or 'Female'.
5. Fill in the ordering physician's full name and contact information, including address, phone number, and fax number.
6. Enter the tax ID of the ordering physician.
7. Complete the section specifying the hospital, facility, or specialist providing services by filling in the name, address, phone number, fax number, and tax ID.
8. Document the patient’s DSM-III-R/DSM-IV diagnosis in the provided space.
9. Check the applicable treatment modalities that will be used by marking the correct boxes.
10. List the current psychotherapeutic medications and their dosages.
11. Provide additional remarks as needed to justify the request for further treatment.
12. Indicate the number of additional visits requested.
13. Specify the frequency of visits by selecting the appropriate option.
14. Obtain the signature of the provider at the bottom of the form.
15. Gather and prepare the required accompanying documents, including the patient's history and physical, clinic records, previous treatment records, and any relevant diagnostic testing results.
16. Submit the completed form and accompanying documents, typically via fax, to the appropriate contact number.
17. Finally, save your changes, then download, print, or share the form as needed.

Complete your Mental Health Services Preauthorization Form online today to ensure timely access to necessary treatments.