BCN Behavioral Health Continuing Outpatient Treatment Request Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the member's name, number, and date of birth in the designated fields. This information is crucial for identification.
3. Fill in the treating clinician's details, including their type (MD/DO, psychologist, etc.) and name. If applicable, include the supervising provider's name.
4. Indicate whether the authorization is for an individual or organization by selecting the appropriate option and providing necessary NPI numbers.
5. Document the member’s treatment history, including total time spent with this practitioner and cumulative time with all practitioners.
6. Complete sections on current therapy modality and prior treatment types by checking relevant boxes based on the member's history.
7. Record current DSM-5 diagnosis and any significant changes since the last review in the provided fields.
8. Finally, ensure that all required signatures are included before faxing the completed form to 1-866-364-7145.

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