Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to obtain the Behavioral Health Inpatient Authorization Form and open it for editing.
2. Provide the facility information by entering the facility name and provider tax ID. In the service address section, input the complete address of the facility.
3. Fill out the member information. Write the last name, first name, Priority Health ID number, and date of birth of the member requiring authorization.
4. Select the type of request by checking the appropriate box: pre-service, concurrent, or retrospective.
5. Indicate the level of care by checking the box that corresponds to the service being requested, such as mental health inpatient or inpatient detox.
6. Input specific dates of service requested in the designated field.
7. Provide the name of the attending psychiatrist in the corresponding line.
8. If applicable, enter the discharge date and complete the relevant Axis fields (I, II, III, IV, and V).
9. List any discharge medications clearly in the provided section.
10. Detail the follow-up care needed by filling in the therapy, psychiatry/PCP, and other appointments sections.
11. Enter the current phone number for member follow-up in the designated line.
12. Complete the contact information of the reviewer requesting authorization, including name, title, and phone/fax.
13. Finally, include any additional comments as necessary and ensure all fields are completed before proceeding.
14. Once finished, save changes, and then you can download, print, or share the completed form.

Start filling out the Behavioral Health Inpatient Authorization Form online for a smooth submission.