Mental Health Service Pre-Authorization Request
Patient Information
Patient Name
Date of Birth
Member ID
Insurance Plan
Provider Information
Provider Name
NPI
Phone
Fax
Requested Services
Service Type
Psychiatric Evaluation
Individual Therapy
Group Therapy
Medication Management
Other
CPT/Service Code
Number of Sessions/Units
Start Date
Clinical Information
Diagnosis (ICD-10)
Clinical Summary / Rationale
Additional Notes