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Get ValueOptions Outpatient Retrospective Review Form 2014-2024

Tient’s Name: _________________________ DOB: _______________ Sponsor #: DSM Diagnosis Axis I - Axis II - TREATMENT REPORT Clinical Information for each date of service is required to support medical necessity and to validate services rendered. (Attach additional clinical notes if necessary.) INDIVIDUALS PRESENT IN SESSION: REQUESTED AUTHORIZATION: (limit 8 dates of service per form.) CPT Code: DATE(S) OF SERVICE: CPT Code: DATE(S) OF SERVICE: CPT Code: DATE(S) OF SERVICE: Provider Na.

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