Transcription of Medicaid Electroconvulsive Therapy (ECT) Autorization ...
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Medicaid Electroconvulsive Therapy (ECT) Autorization ...
SUBMIT TOUtilization Management Department Phone: 1-877-644-4623 Fax: 1-844-824-7705 _____ Electroconvulsive Therapy (ECT) Autorization REQUEST FORMP lease print clearly incomplete or illegible forms will delay processing. DEMOGRAPHICSP atient Name _____ DOB _____SSN _____Patient ID _____Last Auth # _____ PREVIOUS BH/SUD TREATMENT None or OP MH SUD and/or IP MH SUD List names and dates, include hospitalizations _____Substance Abuse None By History and/or Current/ActiveSubstance(s) used, amount, frequency and last used _____ _____ CURRENT ICD DIAGNOSIS Primary _____ R/O _____ R/O _____ Secondary _____ Teritary _____ Additional _____ Additional _____ CURRENT RISK/LETHALITY 1 NONE 2 LOW 3 MOD* 4 HIGH* 5 EXTREME* SuicidalHomicidalAssault/ Violent BehaviorPsychoticSymptoms*3, 4, or 5 please describe what safety precautions are in place_____ _____ PROVIDER INFORMATIONP rovider Name (print) _____ Hospital where ECT will be performed_____ _Professional Credential: MD PhD Other _____ P
Has information been shared with the PCP regarding Behavioral Health Provider Contact Information, Date of Initial Visit, Presenting Problem, Diagnosis, and Medications Prescribed (if applicable)?
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