Treatment Authorization Request Form Final 04242017 2026

1. Click ‘Get Form’ to open the Treatment Authorization Request Form Final 04242017 in the editor.
2. Begin by entering the 'Date of Referral' and 'Referring Agency Provider #' at the top of the form. Ensure that all required fields are filled accurately.
3. Fill in the 'Referring Agency Staff' and their contact information, including phone and fax numbers, to facilitate communication.
4. Provide details about the recommended FBS provider and include any rationale for this recommendation if applicable.
5. Ensure consent is obtained from a parent or guardian over age 14 for information release. Mark 'Yes' or 'No' and provide the date consent was received.
6. Complete member details such as name, MA ID #, DOB, current age, gender, and race (optional).
7. List caregiver(s) and legal guardian(s) along with their relations to the member. Include home address and contact information.
8. Document any other agencies involved in the member's care and provide a DSM-5 diagnosis if available.
9. Discuss family dynamics and reasons for referral in detail to give context to the request.
10. Finally, review all sections for completeness before submitting your form through our platform for processing.

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