Provider Attestation (Expedited Requests Only) Clinical justification for expedited review:

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1 Inpatient Treatment Request Fax completed form to: Fill out completely to avoid delays Date: / / Request Type (Check one): Standard Expedited (additional information required below) Provider Attestation (Expedited Requests Only) Clinical justification for expedited review: By signing below, I certify that applying the standard review timeframe for this service request may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function. Physician/clinician name: Signature: Identifying Data First: Middle: Last: Health Plan ID: Date of Birth: / / Gender: Male Female Address: State: Zip: Provider Information Provider name: NPI#: Phone: ( ) Fax: ( ) Other Current BH Provider(s) Check one: Member agreed to release of information to their PCP and/or other treating providers dated. Member has been informed for release of information and has declined. Diagnoses Axis I Axis V Axis II Axis IV Axis III Highest GAF in past year:

2 Psychotropic Medications Medication Previous or current? Changed since last report? Dosage Frequency Adherent? Clinical Information Check all that apply Persistent Persistent Anxiety Disorders Obsessions/compulsions Generalized Anxiety Panic Attacks Phobias Somatic complaints PTSD symptoms Depression Impaired concentration Impaired memory Psychomotor retardation Sexual issues Appetite disturbance Irritability Agitation Sleep disturbance Hopelessness/Helplessness Mania/Hypomania Insomnia Grandiosity Pressured Speech Racing thoughts/flight of ideas Poor judgment/impulsivity Sexual preoccupation Psychotic Disorders Delusions/paranoia Self care deficits Hallucinations, Type: Responding to Internal Stimuli Disorganized thought process Loose associations Substance Use Disorder Loss of control of dosage Amnesic episodes Legal problems Alcohol abuse Opiate abuse Prescription medication abuse Polysubstance abuse Personality Disorder Oddness/eccentricities Oppositional Disregard for law Recurring self injuries Sense of entitlement Passive aggressive Dependency Manipulation Page 2 of 5

3 Co occurring Medical Conditions Chronic Chronic Risk Factors Check all that apply Risk Factors None Ideation with plan Ideation without plan Intent with means Intent without means Current? Suicide Homicide Abuse None Victim Patient is Perpetrator Does abuse or neglect involve a child or elder? Abuse has been legally reported Current? Physical Sexual Family/Interpersonal relationships Barriers / Risk Factors Social History (Last 3 years if known) Current or Current Supports/Protective Factors Job/School Housing Family History of Mental Illness / Substance Use Disorder Page 3 of 5

4 Treatment History Level of Care Inpatient psychiatric Inpatient Substance Use Disorder Partial Hospitalization (PHP) # of distinct episodes/ sessions Date of last treatment All levels of care Level of Care Intensive Outpatient (IOP) Outpatient psych (individual or group) Outpatient substance abuse (individual or group) # of distinct episodes/ sessions Date of last treatment Treatment Goals 1. Treatment Goals and Outcomes Complete fields below and/or attach current treatment plan Objective outcome criteria by which goal will be measured: Expected Outcome and Prognosis (check all that apply) Return to normal functioning Expected improvement, anticipated less than baseline functioning Relieve acute symptoms, return to baseline functioning Maintain current status, prevent deterioration Discharge/Termination Plan (include estimated discharge date) Page 4 of 5

5 Requested Authorizations Service 1 Code # Units requested Service Start Date Service End Date 2 3 Requested by: Phone: Fax: Fax completed form to: Fill out completely to avoid delays Page 5 of 5

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