Cenpatico behavioral health of arizona pm form 3.14.4 out-of ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the Participant’s Information section, including the CIS Number, Name, Mailing Address, Date of Birth, and Fund Type. Ensure all fields are accurately completed.
3. In the DSM-IV Diagnostic Codes section, provide the necessary codes for Axes I & II. This is crucial for processing your request.
4. Detail the Clinical Rationale for Referral and anticipated aftercare following the requested services. Attach any relevant service plans as needed.
5. Move to the Requested Out-Of-Network Services section. Clearly state the reason for your OON request and fill in the anticipated start date along with requested service codes.
6. Complete the Out-of-Network Provider Information section with details about your chosen provider, ensuring you include their credentials and contact information.
7. Finally, review all entries for completeness before submitting. Remember that incomplete forms will not be processed.

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