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Get MN Universal Outpatient Mental Health/Chemical Health Authorization Form 2002-2024

Ealth Authorization Form Provider Name: Degree/License Type: Clinic Name: Mailing Address & Fax: (see instructions) Patient Name: Patient Address: Subscriber Name: Health Plan Name: Health Plan/Group Number: Member ID: Patient DOB: Is this treatment court-ordered? No Yes (If yes, submit order and evaluation) Number of Sessions to date: Frequency Date of most recent visit Date 1st Visit (present episode of care) Release of information for payer signed: Yes No Release of information for PCP signe.

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