Get Behavioral Health Outpatient Authorization Request Form. Use This Form To Request Behavioral Health

Filling out the Behavioral Health Outpatient Authorization Request Form accurately is crucial for accessing necessary treatment. This guide will provide you with detailed, step-by-step instructions to ensure a smooth completion of the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the member information by filling in the last name, first name, Priority Health ID number, and date of birth.
3. Indicate the type of request by selecting one of the options provided: TMS, ADD/ADHD testing, psychiatric services, substance use disorder- intensive outpatient, psych testing, therapy, or Medicare organization determination.
4. Enter the treatment provider's name and their tax ID. If applicable, provide the group or facility name and service address.
5. For TMS requests, ensure that a clinical record is faxed alongside this form. For intensive outpatient concurrent reviews related to substance use disorder, include the clinical record as well.
6. Specify the mental health issues being addressed by checking the appropriate boxes, including ADD/ADHD, anxiety, depression, or any other issues, with space to provide additional details.
7. Indicate the presence of any serious issues such as suicidal thoughts, homicidal thoughts, psychosis, or symptoms of drug or alcohol withdrawal.
8. State whether there are any current behavioral health services being received through Community Mental Health by selecting 'Yes' or 'No,' and provide specific details if applicable.
9. Note if there has been any hospitalization in a psychiatric setting within the past two years by selecting 'Yes' or 'No'.
10. Fill in the contact information of the office administrator requesting the authorization, including their name, address, and type of office (e.g., behavioral health provider office, PCP office, facility, or other).
11. Provide contact details such as phone or fax numbers for the office administrator.
12. Complete any additional comments if necessary before submitting the form.
13. Once all fields are filled out accurately, save your changes, download, print, or share the completed form as needed.

Complete your Behavioral Health Outpatient Authorization Request Form online today to ensure timely access to your healthcare.