Therapeutic Behavioral On-Site Services for Children & Adolescents’ Re-Certification Request
Date:
Demographics
Submission of this form constitutes a request for re-authorization of coverage for Therapeutic Behavioral On-Site
(TBOS) services for the member referenced below. Complete information is required for AMERIGROUP to complete
the review of this request. A licensed mental health clinician must sign this form prior to coverage authorization of
TBOS services. Fax completed and signed referral forms to 1-800-505-1193, ATTN: Behavioral Health Case
Management. Thank you.
Male
Member name
Member ID
(Medicaid or AMERIGROUP #)
SED
Provider Info
Grade
EH
Special Education
Age
Date of Birth
Female
Sex
Dates
ESE
Other-specify
N/A
Out-of-School Suspensions within the last 3 months
326476
Adapt Behavioral Services
Agency
Referring clinician
Provider number
( 407 ) 622-0444
( 407 ) 699-0444
solder@adapt-fl.com
Telephone number
Fax number
Email
Clinical Description
Provide specific details of behaviors & symptoms within the last month in home/school environments which
necessitate the continuance of TBOS services to prevent a more restrictive behavioral health placement
3/7/2012
FL Plan
Page 1 of 3
Treatment Plan
Describe specific changes in the treatment plan directly related to interventions & treatment modality/frequency
Aftercare
Describe in detail the aftercare/step down plan by identifying agency and services needed
Clinical Impression
Code
List any & all current medications as well as psychiatric
medications including dose and frequency
None
Medication
Dose
Frequency
Diagnosis
I
II
III
IV
V
*Please note:
Automatically submit
(If available)
Past 3 psychiatric evaluation notes,
past 2 months of TBOS treatment
notes, most recent updated
treatment plan including any other
clinical documentation that would
be helpful.
List family members, caretakers,
or legal guardians that have
participated in therapy
3/7/2012
FL Plan
Page 2 of 3
Requested Units
Credentials
Maximum number of requested units per Medicaid handbook cannot exceed 36 units (9 hours/month) for combined HO (therapy)
and HM (behavioral management). HN units cannot exceed 128 units (32 hours/ month). Approved units will not exceed 6 months
HO units per month
HM units per month
HN units per month
I hereby certify as a clinician of the healing arts of behavioral health that I have reviewed this authorization for
the above Amerigroup member and he/she meets the Medicaid Community Mental Health Handbook’s criteria
for TBOS services.
PY4781
Clinician’s Signature
Credentials
Date
List any current or past medical and
surgical conditions
None
Date
3/7/2012
FL Plan
Page 3 of 3
Conditions/diagnosis
TBOS units
16 units = 4 hr/month
20 units = 5 hr/month
24 units = 6 hr/month
28 units = 7 hr/month
32 units = 8 hr/month
36 units = 9 hr/month