Electroconvulsive Therapy (ECT) Authorization Request Form
________________________________________ ___________________________ ________________________________________ ___________________________ _______________________________________ ________________________________________ _______________________________ ________________________________________ _______________________________ SUBMIT TO Utilization Management Department 1145 Broadway, Suite 300 Tacoma, WA 98402 PHONE: FAX 1-833-286-1086 Electroconvulsive Therapy (ECT) Authorization Request Form *All Fields Must Be Completed For This Request To Be Reviewed.
ELECTROCONVULSIVE THERAPY (ECT) Authorization Request Form *All Fields Must Be Completed For This Request To Be Reviewed. Please type or print neatly. Please indicate which level of care the member is currently engaged: INPATIENT OUTPATIENT . DEMOGRAPHICS . Patient Name . Patient Last Name . DOB . SSN .
Download Electroconvulsive Therapy (ECT) Authorization Request Form
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