VBH-PA HEALTH CHOICES D&A OUTPATIENT AUTHORIZATION REPORT

							                                       VBH-PA HEALTH CHOICES FAX TO 855-439-2444
                        DRUG AND ALCOHOL OUTPATIENT AUTHORIZATION REPORT
                                                  520 Pleasant Valley Road, Trafford, PA 15085
Check One:         Initial Outpatient Authorization Report                Continuing Outpatient Authorization Report

                        DEMOGRAPHICS                                                             Other Community Services

                                                                            What other treatment or community service is the member
Member’s Name:
                                                                            receiving? (Please check all that apply)
Date of Birth:__ __/__ __/__ __ Age: ______ Gender:                          None                           Behavioral Health Rehabilitation
                                                                                                               Services
Member’s MA ID#:
                                                                             Self Help Groups               Mental Health
Member’s Address:                                                            MH Case Management  Family Based Treatment
                                                                             D&A Intensive Case             Psych/Social Rehabilitation
City:                     State:          Zip:
                                                                              Management
                                                                             MISA                           Other (specify)______________
Telephone Number:          Home:
                           Work:                                                                         AXIS I Diagnosis
                           PROVIDER                                                     (if not available, Service Manager will complete)
                                                                            * /___/___/___/ - /___/___/
Name of Provider:
                                                                            /___/___/___/ - /___/___/
                                                                            /___/___/___/ - /___/___/
Provider ID Number:
___________________________________________________                         * Not Applicable for SCA
Provider’s Service Address:




City:                     State:          Zip:
Contact Person:
Telephone Number:

Fax Number_________________________________________




                                                  Frequency
          TYPE OF SERVICE                        (e.g. 1x/wk.,     Auth Begin Date        Auth End Date                        Units
                                                    1x/mo.)

 Psychotherapy

 Group Therapy (15 min)

 Family Psychotherapy (15 min)

 Psychiatric Evaluation

 Medication Management
                                                     N/A
 ICM (15 Min)
 IOP                                         ______Hrs/Day

 PHP                                         _____Days/Wk


 Other

                                                                                                                            Revised 04/18/11