AUTHORIZATION FORM
Date:___________________________Referral Source:___________________________ Client:__________________________________________________________________ Client DOB:_____________________Subscriber ID#:____________________________ Hm #:__________________________Wk #:____________________________________ Cell #:__________________________Other #:__________________________________ Employee Name:________________________Employer:_________________________ Group Policy #:___________________________________________________________ Phone # to Verify Coverage:_________________________________________________ (office use) First Appt Offered:_________________Appt. Accepted:_________________
Additional form for EAP Clients:
Date:___________________________________________________________________ EAP Company:___________________________________Agent:__________________ Authorization #:__________________________________________________________ Number of Sessions Approved:______________________________________________ Effective Date:__________________________Expiration Date:____________________
Additional form for Managed Care Clients Only (UBH, Value Options, UnitedHealthcare):
Date:___________________________________________________________________ MC Company:___________________________________________________________ Authorization #:__________________________________________________________ Number of Sessions Approved:______________________________________________ Effective Date:______________________________Expiration Date:________________ Deductible:_________________________________Amount Satisfied:_______________ Co-Pay:____________________________________Other:________________________