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					                       OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                                 Page 1 of 13
                                                                                                                                  Revised 01-14-08
                                                      APS Healthcare, Inc.
                                                4545 Lincoln Boulevard Suite 103
                                                    Oklahoma City, OK. 73105
                                               800-762-1560 (Main)/800-762-1639 (FAX)
FAX DATE:

TIME:

TYPE OF FAX: (Mark only ONE of the following by typing “X”)

     1. INITIAL REQUEST                                                         5.   IMPORTANT NOTICE RESPONSE
                                                                                     (Attention: Reviewer)

     2. EXTENSION REQUEST                                                        6. PENDING ELIGIBILITY RESPONSE
                                                                                    (Attention: Reviewer)

     3. MODIFICATION REQUEST                                                    7.   PROVIDER CHANGE OF DEMOGRAPHIC
         (Attention: Reviewer)                                                       INFORMATION (Attention: Clerical Staff)

     4. CORRECTION REQUEST
        (Attention: Reviewer)

         OTHER

TO: APS – Medicaid Outpatient Preauthorization Unit                             ATTENTION:
FAX NUMBER: (800) 762-1639                                                                    (Reviewer)

FROM: FACILITY/AGENCY: MULTI-COUNTY COUNSELING, INC.

CONTACT NAME:

PROVIDER ID #: 100746700H                                                 CASE MGMT ID #:

Check One:             Mental Health Request                                         Substance Abuse /Integrated Request
                                             TH
FACILITY ADDRESS: 1719 SW 11                      Street                LAWTON                  OKLAHOMA                73501
                                            Street                            City                    State              Zip
FAX NUMBER: (405) 527-1084 PHONE NUMBER: (405) 527-1785

RE: CLIENT NAME:
                         First, MI, Last, Designation (Sr., Jr., III, etc.)
RECIPIENT ID #:                                                                       PA #:
                                                                                                           (If Applicable)
NUMBER OF PAGES INCLUDING THIS PAGE:

COMMENTS: (NO clinical information)




                                                                     CONFIDENTIALITY
The documents included in this transaction may contain confidential information from the APS Healthcare, Inc. The information is intended
for the use of the person or entity name on this transmittal sheet. If you are not the intended recipient, be aware that any disclosure, copying,
distribution or use of the contents of this transmission is prohibited. If you have received this transmission in error, please immediately
telephone the APS Healthcare, Inc. so that we can arrange for the disposition of the transmitted documents.
                       OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                            Page 2     of   13

Client Name:
                   First, MI, Last, Designation (Sr., Jr., III, etc.)

Social Security #                                              Legal Guardian Name: __________________________________

Relationship to Client:                                             Date of Birth:                        Age:          Sex:
                                                                                 MM/DD/YY

Current Residence: (Mark ALL that apply by entering “x”)

        Systems of Care                Individual Home                  Residential Care Facility         Group Home (Level___)

        Nursing Home                   Shelter                          ICF/MR (Admit Date:                        )

        DHS/OJA/IH Custody (Worker:                                                  Phone#                        )

        Foster Care (Placement Date:                                     )            TFC

        Multiple placements in past 2 years (#                                              )

LEVEL:         1           2          3          4             Exceptional Case             0-36 months       ICF/MR           RBMS

ADMIT DATE TO CURRENT FACILITY:

    TREATMENT HISTORY: (Admit / Discharge dates, facility, IP or OP, reason for treatment)




ICD-9-CM DIAGNOSES and DSM Axes: (Complete ICD-9-CM diagnoses and DSM axes):
Axis I: ICD-9-CM (code and title):




Axis II:


Axis III:
Axis IV: Problems related to:                 Primary support group              Social environment         Education          Housing
    Economic            Occupation                   Access to health care services             Interaction with legal system/crime
Other
Axis V: Current GAF:                        Highest Level in the Past Year:
HISTORICAL INFORMATION (relevant to current diagnosis and treatment): _________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
                      OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                         Page 3     of   13
CLIENT ASSESSMENT RECORD                                                                                             Past     Current
1. FEELINGS/MOOD/AFFECT                                                                                      SCORE
Problem areas:       Mood lability          Coping skills       Suicidal/homicidal ideation/plan        Depression

                     Anger              Anxiety              Euphoria           Change in appetite/sleep patterns.
Evidenced by (specific examples, frequency, duration and intensity, and impact on daily functioning)




2. THINKING/MENTAL PROCESS                                                                                   SCORE
Oriented x        MMSE score (if administered)                   IQ Score (if MR diagnosis)

Problem areas:         Memory          Cognitive process          Concentration          Judgment             Obsessions

                       Delusions/hallucinations             Belief system            Learning disabilities       Impulse Control
Evidenced by (specific examples, symptom frequency, duration and intensity, impact on daily functioning):




3. SUBSTANCE USE:                                                                                            SCORE _______       _______
Drug of Choice               Amount Used               Frequency of Use              First Used                   Last used




Functional impact of current use, give examples of level of dependency




4. MEDICAL/PHYSICAL                                                                                          SCORE _______       _______
Current Medical/physical conditions




Impact/limitations on day-to-day function



MEDICATIONS
Name of Rx                                     Dosage/Frequency                                       Reason for Rx________________
                     OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                       Page 4    of   13
5. FAMILY                                                                                                 SCORE _______        _______
Currently resides with:     Biological family         Adoptive family           Foster family        Alone          Other
Problem areas:              Parenting           Conflict        Abuse/violence           Communication
                             Marital            Sibling         Parent/child
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning) ____________________




6. INTERPERSONAL                                                                                          SCORE _______        _______
Problem areas:        Peers/friends         Social interaction           Withdrawal          Make/keep friends          Conflict
Evidenced by (specific examples, frequency, duration, intensity, impact on daily functioning) _______________________




7. ROLE PERFORMANCE                                                                                       SCORE _______        _______
Functional role:      Employment/Volunteer                 School/daycare         Home management             Other
Effectiveness of functioning in identified role:
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning) ____________________




8. SOCIO-LEGAL                                                                                            SCORE _______        _______
Problem areas:        Ability to follow rules/laws           Authority issues         Legal issues       Aggression
         Probation/parole        Abides by personal ethical/moral value system               Antisocial behaviors
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning) ____________________




9. SELF-CARE/BASIC NEEDS                                                                                  SCORE _______        _______
Problem areas:        Hygiene          Food               Clothing          Shelter          Medical/dental needs
                      Transportation
Evidenced by (specific examples, frequency, duration and intensity, impact on daily functioning)




10. COMMUNICATION (required for ICF/MR level of care)                  ESL            Hearing impaired        Non-verbal
        Uses interpreter          Signs            Uses mechanical device                Speech impaired            Fluency
                   OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                 Page 5   of   13
INTERPRETIVE SUMMARY/ADDITIONAL INFORMATION:
                   OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                  Page 6   of   13
                                      MENTAL HEALTH SERVICE PLAN

                                   Low Complexity          Moderate Complexity

PROBLEM 1:
GOAL 1:

CURRENT OBJECTIVES: (Must be behaviorally measurable)

1a:



1b:



1c:



1d:



          TYPE OF SERVICE                       DATE INITIATED                   TARGET DATE

1a:

1b:

1c:

1d:
                   PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
                                       (Extension Requests Only)
                   OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                  Page 7   of   13



PROBLEM 2:
GOAL 2:

CURRENT OBJECTIVES: (Must be behaviorally measurable)

2a:



2b:



2c:



2d:



          TYPE OF SERVICE                       DATE INITIATED                   TARGET DATE

2a:

2b:

2c:

2d:
                   PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
                                       (Extension Requests Only)
                   OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                  Page 8   of   13

PROBLEM 3:
GOAL 3:

CURRENT OBJECTIVES: (Must be behaviorally measurable)

3a:



3b:



3c:



3d:



          TYPE OF SERVICE                       DATE INITIATED                   TARGET DATE

3a:

3b:

3c:

3d:
                   PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
                                       (Extension Requests Only)
                   OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                  Page 9   of   13



PROBLEM 4:
GOAL 4:

CURRENT OBJECTIVES: (Must be behaviorally measurable)

4a:



4b:



4c:



4d:



          TYPE OF SERVICE                       DATE INITIATED                   TARGET DATE

4a:

4b:

4c:

4d:
                   PROGRESS ON CURRENT/PREVIOUS GOAL SINCE LAST AUTHORIZATION:
                                       (Extension Requests Only)
                    OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                           Page 10    of   13



SIGNATURE PAGE

I/We (client/guardian) have actively participated in the development of this service plan and understand the treatment
goals and objectives listed. I have the following comments/response:



I/We        Agree       Disagree with this service plan.
Mark One Response


Client Signature, 14 or older                  Date                  Parent/Guardian Signature                   Date

Witness:                                   Relationship to client:

If unable to sign, document reason:

TREATMENT TEAM:

Responsible MHP Signature, Degree/License             Date               Physician, Credentials           Date ________
                                                                                    Physician signature not required

Type of          Frequency                 Staff/Credentials                        Signature                       Date
Service     of Service per week                 (Print)

Ind Psy

Int Psy

Grp Psy

Fam Psy

P/S Reh-G

P/S Reh-I

A/D Skill/Dev -G

A/D Skill/Dev-I

Psy Test

Med T/ S

C/M
                    OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                              Page 11      of   13
                                                       ADDENDUM
Completion of this page of the request packet is optional for the provider and is not required for the preauthorization
process at APS. The items listed on this page, however, may be required documentation for SURS reviews, CARF
certification and/or JCAHO certification. Please do not submit this form to APS as part of the request packet unless
instructed as a specific request by an APS review coordinator.
COMMUNITY INTEGRATION:


CAREGIVER RESOURCES (for clients under the age of 22):


CLIENT’S STRENGTHS/ABILITIES (in client’s own words):


CLIENT’S LIABILITIES/NEEDS (in client’s own words):


THEORETICAL APPROACH BEING UTILIZED WITH INDIVIDUAL PSYCHOTHERAPY:


COLLABORATION WITH SCHOOL SYSTEM (school age children only):


REFERRALS TO OTHER COMMUNITY SERVICES:


DISCHARGE PLAN:

a. CRITERIA (client-specific behaviors):


b. ESTIMATED DATE OF DISCHARGE (M/Y):

c. AFTERCARE PLAN:
                       OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                                Page 12 of 13
                                                                                                                               Revised 01-09-08
Recipient ID #:                             Provider #: 100746700H             Location:                        Case Mgmt:

                                           CHILD RVU PAGE (under 21 years old)
CHILD Psychotherapy:
Child Individual Psychotherapy:                # of 20-30 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 1.54 RVU’s)
                                               # of 45-50 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 2.25 RVU’s)
                                               # of 75-80 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 3.34 RVU’s)

Child Interactive Psychotherapy:               # of 20-30 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 1.64 RVU’s)
                                               # of 45-50 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 2.43 RVU’s)
                                               # of 75-80 min sessions per total review period =            RVU total
                                                                                                           (1 unit = 3.51 RVU’s)
Child Family Psychotherapy w/ Client:
                                               # of 60 min sessions per total review period =               RVU total
                                                                                                           (60 min = 2.69 RVU’s)
Child Family Psychotherapy w/o Client:
                                               # of 60 min sessions per total review period =               RVU total
                                                                                                            (60 min = 2.20 RVU’s)

Child Group Psychotherapy:                     # of 60 min sessions per total review period =               RVU total
                                                                                                            (60 min = 0.84 RVU’s)
    Total CHILD Psychotherapy RVU’s per total review period =

CHILD Psychosocial Rehabilitation or Alcohol and/or Substance Abuse Treatment Services, Skills Development and Case Management
           For Rehab and Case Management: Each 60 min. session equals 4 units and RVU’s have been adjusted accordingly.

Child Group Rehab:                             # of 60 min sessions per total review period =                RVU total
     Or Skills Development                                                                                  (60 min = 0.56 RVU’s)

Child Individual Rehab:                        # of 60 min sessions per total review period =                RVU total
     Or Skills Development                                                                                  (60 min = 1.48 RVU’s)

Child Case Management: Direct                 # of 60 min sessions per total review period =                 RVU total
                                                                                                            (60 min = 1.76 RVU’s)

Child Case Management: Indirect                # of 60 min sessions per total review period =                RVU total
                                                                                                            (60 min = 1.4 RVU’s)

    Total CHILD Rehabilitation/Skills Development/Case Management per total review period =

                                                 Combined Total CHILD RVU’s =

Requested Authorization Dates:           Start Date:                       6 month              Other – please circle 1 / 2 / 3 / 4 / 5 month

Additional / Optional CHILD Services:

CHILD Medication Training and Support:                                                          # of sessions per review period
CHILD Psychological Testing:                                                                    # of hours
CHILD Behavioral Health Aide:                                                                   # of hours
                      OUTPATIENT REQUEST FOR PRIOR AUTHORIZATION
Client Name:
Provider Number:
Date Completed:                                                                                                               Page 13 of 13
                                                                                                                               Revised 01-09-08
Recipient ID #:                            Provider #: 100746700H            Location:                         Case Mgmt:

                                        ADULT RVU PAGE (21 years old and older)
ADULT Psychotherapy:
Adult Individual Psychotherapy:              # of 20-30 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 1.01 RVU’s)
                                                                                                         (Private    1 unit = 1.54 RVU’s)
                                             # of 45-50 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 1.92 RVU’s)
                                                                                                         (Private    1 unit = 2.25 RVU’s)
                                             # of 75-80 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 3.13 RVU’s)
                                                                                                         (Private    1 unit = 3.34 RVU’s)
Adult Interactive Psychotherapy:             # of 20-30 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 1.06 RVU’s)
                                                                                                         (Private    1 unit = 1.64 RVU’s)
                                             # of 45-50 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 2.01 RVU’s)
                                                                                                         (Private    1 unit = 2.43 RVU’s)
                                             # of 75-80 min sessions per total review period =            RVU total
                                                                                                         (DMH/Public 1 unit = 3.28 RVU’s)
                                                                                                         (Private    1 unit = 3.51 RVU’s)
Adult Family Psychotherapy w/ Client:        # of 60 min sessions per total review period =                RVU total
                                                                                                         (DMH/Public 1 unit = 2.53 RVU’s)
                                                                                                         (Private    1 unit = 2.69 RVU’s)
Adult Family Psychotherapy w/o Client:       # of 60 min sessions per total review period =                RVU total

(DMH/Public 1 unit = 2.53 RVU’s)
                                                                                                         (Private     1 unit = 2.20 RVU’s)
Adult Group Psychotherapy:                   # of 60 min sessions per total review period =                RVU total
                                                                                                                     (DMH/Public 1 unit = 1.21
RVU’s)
                                                                                                         (Private      1 unit = 0.76 RVU’s)

    Total ADULT Psychotherapy RVU’s per total review period =

             ADULT Psychosocial Rehabilitation or Alcohol and/or Substance Abuse Treatment Services, Skills Development
                                                       and Case Management
For Rehab and Case Management: Each 60 min. session equals 4 units and RVU’s have been adjusted accordingly.

Adult Group Rehab:                          # of 60 min sessions per total review period =                RVU total
    Or Skills Development                                                                                (DMH/Public 60 min = 0.48 RVU’s)
                                                                                                         (Private    60 min = 0.40 RVU’s)
Adult Individual Rehab:                     # of 60 min sessions per total review period =                RVU total
    Or Skills Development                                                                                (DMH/Public 60 min = 1.80 RVU’s)
                                                                                                         (Private    60 min = 1.44 RVU’s)
Adult Case Management: Direct               # of 60 min sessions per total review period =                RVU total
                                                                                                         (DMH/Public 60 min = 1.96 RVU’s)
                                                                                                         (Private    60 min = 1.52 RVU’s)

    Total ADULT Rehabilitation/Skills Development/Case Management per total review period =

                                                 Combined Total ADULT RVU’s =

Requested Authorization Dates:     Start Date:                            6 month            Other – please circle number 1 / 2 / 3 / 4 / 5
                                                 month
Additional / Optional ADULT Services:
ADULT Medication Training and Support:                                            # of sessions per review period
ADULT Psychological Testing:                                                      # of hours

				
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