Behavioral Health Prior Authorization Form Form

Behavioral Health Authorization Request Form ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED & RETURNED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. Rev 05082025 To submit PA electronically access the portal at countycare.valence.care Fax completed form to: 1-800-498-8217 Phone number: 1-855-444-1661

• = Required Information Requestor’s Contact Name: Requestor’s Contact Number: PATIENT INFORMATION Member Name: Date of Birth: Member ID Number: Member Phone Number: Service is: ☐Elective/ Routine ☐Expedited/ Urgent Select Expedited/Urgent to prevent serious deterioration in health or ability to regain maximum function. ☐Extension to Authorization ___ ☐Continuity of Care Concern: SERVICE TYPE ☐Intensive Outpatient (IOP) ☐Electro Convulsive Therapy ☐Outpatient Counseling ☐Psych Testing ☐ ☐ ☐ ☐ ☐Residential Treatment Center ☐Other: ☐Community Based Services/ Case Management PROCEDURE INFORMATION ICD-10 Diagnosis: Diagnosis Description: CPT Code: __ Units: ___ CPT Code: __ Units: ___ CPT Code: __ Units: ___
  CPT Code: __ Units: ___ CPT Code: __ Units: ___ CPT Code: __ Units: ___
• Date(s) of Service: PROVIDER INFORMATION Ordering Provider:
  Primary Care Physician Name: NPI: TIN: Fax: Phone Address: Servicing Provider:
  Same as Ordering Name: NPI: TIN: Fax: Phone Address: Facility: N/A Name: NPI: TIN: Fax: Phone Address: Page 1 Same as Facility Inpatient Mental Health Inpatient Chemical Dependency Partial Hospitalization Admit through ER

Behavioral Health Authorization Request Form Visit the provider portal to submit initial authorization requests online at https://countycare.valencehealth.com/Login ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED & RETURNED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. Rev 12042017 CARE COORDINATION UR Department
Discharge Planner
Health Plan Care Coordinator
☐ N/A ☐ N/A ☐ N/A Name: Name: Name: Phone: Phone: Phone: Fax: Fax: Fax: Email: Email: Email: MEDICATION Is Member on current psychiatric and or medical medications? If yes, please complete below. Use separate sheet if more space is needed. Medication Dosage Response Medication Dosage Response SYMPTOM CHECK LIST (Not a substitute for submitting clinical information) Psychosis:
☐ Command Hallucinations ☐ Hallucinations ☐ Delusions ☐ Dissociation ☐ Loose Associations ☐ Paranoia Anxiety: ☐ Panic Attacks ☐ Chronic Worrying ☐ Obsessive Thoughts ☐ Compulsive Behaviors Safety:
☐ Suicidal ideation ☐ Plan ☐ Intent ☐ Means ☐ Homicidal Ideation ☐ Plan ☐ Intent ☐ Means ☐ Property Destruction ☐ Aggression ☐ Verbal ☐ Physical ☐ Fire Setting ☐ Self-Harm Mood: ☐ Depressed Mood ☐ Hypomania ☐ Mania ☐ Excessive Motor Activity ☐ Flight of ideas ☐ Grandiosity ☐ Pressured Speech ☐ Sleep Disturbance ☐ Weight Loss/Gain ☐ Hopelessness Substance Use ☐ Abuse ☐ Dependence ☐ N/A Detoxing Currently ☐ Yes ☐ No ☐ CIWA Score ☐ COWS Score ☐ CINA Score ☐ History of withdrawal seizures ☐ History of delirium tremens ☐ Co-occurring medical condition *If yes, list here _ Developmental Disorders: ☐ Autism ☐ Asperger’s ☐ Mental Retardation ☐ Other Medication Adherence:
☐ Yes ☐ No If no, Name of Medication: _ Date Last Took: _ Other Symptoms: ☐_ ☐_ ☐_ Progress: ☐ Improved ☐ Unchanged ☐ Regressed CLINICAL INFORMATION Page 2