Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the current date at the top of the form to ensure accurate processing.
3. Complete the member information section by providing the member’s full name, date of birth, and member ID number.
4. In the provider information section, fill in the provider's name, agency tax ID number, and NPI sub provider number along with the provider's contact phone and fax numbers.
5. For the current ICD diagnosis, list the primary diagnosis. If applicable, include secondary and tertiary diagnoses in the provided fields.
6. Indicate whether contact has occurred with the primary care provider by selecting 'Yes' or 'No'.
7. Enter the dates when the member was first and last seen by the provider or agency.
8. The functional outcomes section requires the provider to engage in a face-to-face interview with the member. Answer the listed questions based on the member's recent experiences.
9. Assess the level of improvement to date by selecting from 'Minor', 'Moderate', 'Major', or 'No progress to date' as applicable.
10. Complete the symptoms and functional impairment related symptoms sections by checking the appropriate severity for each symptom listed.
11. Conduct a risk assessment by indicating any suicidal or homicidal ideation and confirming if a safety plan is in place.
12. Outline the current measurable treatment goals in the space provided.
13. Fill out the requested authorization section by checking the appropriate service type, frequency, intensity, and requested start and anticipated completion dates.
14. If applicable, provide additional information about previously attempted traditional behavioral health services.
15. Finally, ensure you sign the form at the bottom and include the date before submitting it to the Utilization Management Department.
16. Once completed, save your changes, download, print, or share the form as needed.

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