BEHAVIORAL HEALTH SERVICES REQUEST FOR …
State of missouridepartment of social servicesBEHAVIORAL HEALTH SERVICES REQUEST FOR PRECERTIFICATIONparticipant name (last, first, mi) provider nameparticipant numberbilling provider identifierprovider taxonomy code (if required)date of birthprovider fax numberprovider phone numberprovider signaturedatenumber of hours used on current precertification (if multiple current precertifications, please list type)1. service requested (if requesting family therapy please see reminder in instructions)testing (ages 0-2) hours ______________ precertification start date ______________individual therapy hours ______________ precertification start date ______________family therapy* hours ______________ precertification start date ______________group therapy hours ___________
state of missouri. department of social services. BEHAVIORAL HEALTH SERVICES REQUEST FOR PRECERTIFICATION. participant name (last, first, mi) provider name
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