18004401561 2026

1. Click ‘Get Form’ to open the Mental Health Service Prior Authorization Request Form in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the Member Name, Date of Birth (DOB), and Member ID. If applicable, provide the enrollment date for retroactive enrollment.
3. Next, complete the PROVIDER INFORMATION section. Input details such as Provider Group/Clinic, Contact Name, Phone, Fax, Street Address, City, State, Zip Code, and Provider ID/NPI.
4. In the AUTHORIZATION REQUEST section, specify the start date and estimated duration of care. Then list any primary and co-occurring diagnoses in the DIAGNOSIS section.
5. Fill out the MEDICATION section by listing medications along with their dosage and frequency.
6. Indicate the CA/LOCUS LEVEL OF CARE based on score and select the LEVEL OF CARE REQUESTED from options provided.
7. Complete the REQUESTED CODES section by including codes for services requested along with units/visits and modifiers if necessary.
8. Finally, sign off on the form by entering your name, signature/credential, and date in the SIGNATURE section before submitting it along with any required documents.

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