Get Wa Chpw Mental Health Service Prior Authorization Request Form 2018

This guide provides clear, step-by-step instructions on how to complete the WA CHPW Mental Health Service Prior Authorization Request Form online. Following these instructions will ensure that you provide all necessary information accurately, helping to streamline the authorization process for mental health services.

Follow the steps to complete the authorization request form effectively.

1. Press the 'Get Form' button to download the WA CHPW Mental Health Service Prior Authorization Request Form and open it in your preferred document editor.
2. Begin by filling out the member information section. Provide the member's full name, date of birth (DOB), and member ID. If the member was retroactively enrolled, include the enrollment date as well.
3. In the provider information section, enter the provider group or clinic name, contact person's name, phone number, fax number, and the street address including the city, state, and zip code. Additionally, include the provider's ID or National Provider Identifier (NPI).
4. Specify the authorization request start date and the estimated duration of the episode of care in the corresponding fields.
5. List the primary diagnosis and any applicable co-occurring diagnoses in the diagnosis section. You can include up to four diagnoses.
6. Attach the CA/LOCUS summary report and any other supporting clinical documents required for the authorization request. This ensures that all necessary documentation is submitted together.
7. In the medication section, list out all medications the member is currently taking, including their dosages and frequency. If not applicable, indicate that appropriately.
8. Select the appropriate level of care requested based on the CA/LOCUS assessment. Ensure to check if the recommended level differs from the requested level and provide a reason for any variance.
9. Fill out the requested codes section by indicating the relevant codes for services, including the amount and any modifiers. Be sure to specify the units or visits required for each code.
10. Finally, ensure that the form is signed by the reviewer. Include their printed name, signature or credential, and the date the form is completed.
11. After completing the form, you can save your changes, download the final version, print it for submission, or share it as needed.

Complete the WA CHPW Mental Health Service Prior Authorization Request Form online today to ensure timely processing of mental health service requests.