Get Adult Bh Hcbs Prior And/or Continuing Authorization Request Form

Filling out the Adult BH HCBS Prior And/or Continuing Authorization Request Form is essential for obtaining necessary services. This guide provides clear instructions to help users navigate the form efficiently online.

Follow the steps to accurately complete the authorization request form.

1. Press the ‘Get Form’ button to access the authorization request form and open it for editing.
2. Begin by filling out the member information section. Enter the member's name, date of birth, phone number, and optional email address and home address. Make sure to include the member's Medicaid ID and plan ID.
3. Provide the Adult BH HCBS provider information. Include the provider's name, address, tax ID number, contact person’s name, title, phone number, and email.
4. Specify the Adult BH HCBS requested. You can choose up to three services from the available options, such as education support services or community psychiatric support and treatment. Indicate the anticipated start date, frequency, intensity, duration, and modality for each service.
5. Outline the goals and objectives for the requested services. Clearly state the client's goals and create measurable objectives that can be achieved within the requested period. Accurately reflect the member’s approved Adult BH HCBS Plan of Care.
6. Document any barriers the member may face in achieving their goals and specify strategies to address these challenges.
7. Complete the attestation section, confirming that the member has elected to receive the requested Adult BH HCBS and whether you have communicated with the member’s health home care manager or managed care manager. Sign your name, print it, and fill in your title and date.
8. Review your completed form for any errors or missing information. Once confirmed, you can save your changes, download a copy, print the form, or share it as needed.

Start filling out your Adult BH HCBS Prior And/or Continuing Authorization Request Form online today.