Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the member information. Provide the member's name, date of birth (DOB), member ID, and enrollment date if applicable.
3. Next, fill in the provider information. This includes the provider group or clinic name, clinical contact, street address, physician contact, city, state, zip code, provider ID/NPI, phone number, and fax number.
4. Enter the ICD-10 diagnosis codes. List the primary diagnosis and any applicable co-occurring diagnosis codes in the designated fields.
5. Fill in the existing service authorization number and requested end date for the extension.
6. Select the ASAM level of care being requested and indicate the number of units required for each service needed.
7. Document the estimated duration of the requested episode of care.
8. Provide a complete list of medications prescribed by the substance use treatment provider, including dosage, frequency, start date, and patient response.
9. List the results of the last three alcohol/drug screens performed, including the date and substances tested.
10. For each of the six dimensions related to assessment and scoring, provide a brief summary of the member's needs/strengths and justify your assessment with clinical documentation.
11. Document how the member is progressing under the current treatment plan, revised treatment goals, and the discharge plan/disposition.
12. Finally, ensure to sign and date the form at the specified section and submit it to the designated healthcare plan as instructed.
13. After completing the form, save any changes made, and use the options available to download, print, or share the form according to your needs.

Complete your VA ARTS Service Authorization Review Form - Extension Requests online today.