Psr authorization form 2026

1. Click ‘Get Form’ to open the psr authorization form in the editor.
2. Begin by filling out Section I. Select the MCO by checking one of the options: Anthem, Beacon/Humana, or Virginia Premier. Enter the individual's name, provider details, date of birth, and relevant dates for assessment and admission.
3. Complete the diagnostic information fields (Axis I-V) and list any known medical conditions along with current medications prescribed. Ensure to include dosage, frequency, and prescriber details.
4. In Section II, indicate whether there is an Integrated Care Plan. If 'No', proceed to complete Sections III and IV.
5. For Section III, check applicable psychosocial eligibility criteria that apply to the client. Provide detailed descriptions of current symptoms and behaviors that support your selections.
6. Outline treatment goals in the designated area, noting progress and lack of progress for each goal.
7. Finally, ensure signatures are obtained from both QMHP and LMHP in Section IV before submitting the completed form via fax to the appropriate MCO.

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