Date:
Billing Provider:
Billing Address:
TIN:
Contact Person:
Phone:
Fax:
Patient:
DOB:
Member:
Member Id:
ICD 10 Diagnosis Code(s):
Stressors:
History of psychiatric treatment - Dates and number of previous hospitalizations and length of time patient has been in outpatient care:
Significant diagnostic changes:
Describe current symptoms that are the primary focus of treatment and progress in treatment:
Current Medications - Name, dosage frequency and response to medications:
Treatment Goals - Include time frame to meet goals:
Describe the proposed treatment and why you consider it to be medically necessary at this time:
Please indicate type of services, number of sessions, frequency of sessions, start and stop date:
CPT code:
Number of sessions:
Frequency of sessions:
Start date:
Stop date:
CPT code:
Number of sessions:
Frequency of sessions:
Start date:
Stop date:
CPT code:
Number of sessions:
Frequency of sessions:
Start date:
Stop date:
Intensive Outpatient Program:
Number of sessions:
Frequency of sessions:
Start date:
Stop date:
Select one billing code:
RevCode 0905         RevCode 0906         S9480
Estimated discharge date:
Discharge plan:
NOTE: Certification is valid only for covered billing codes. If non-covered codes/items are billed, they will not be covered by the plan, and will be the member's financial responsibility
If you are requesting a retroactive review, please list all dates of services and CPT codes you are requesting authorization for below.
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** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.