Ambetter - OUTPATIENT TREATMENT REQUEST FORM
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First Name
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Last Name
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Provider Name
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Provider/Agency NPI Sub Provider #
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Phone Number
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Fax Number
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Primary Diagnosis
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Therapeutic Approach/Evidence Based Treatment Used:
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Member Name
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Current Measurable Treatment Goals (97151, 97152)
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Authorization Request Dates: 02/06/2023 to 08/05/2023 97151 - 32 total units per 6 months 97152 - 8 total units per 6 months
Current Measurable Treatment Goals (97153, 97154, 97155, 97156)
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Authorization Request Dates: 02/06/2023 to 08/05/2023 97153 - 3810 total units per 6 months 97154 - 90 total units per 6 months 97155 - 520 total units per 6 months 97156 - 104 total units per 6 months
REQUESTED AUTHORIZATION PLEASE CHECK OFF APPROPRIATE BOX TO INDICATE MODIFIER, IF APPLICABLE
ANTICIPATED COMPLETION
Behavioral Health Outpatient Services
Individual Psychotherapy-Mental Health
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Clinician Signature
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