SCHA # 2285 (1/2014)
Outpatient Mental Health Authorization
Submit Fax Request to:
888-889-7822
Or Mail to:
Mayo Clinic Health Solutions
PO Box 211698
Eagan, MN 55121
SCHA Provider Services
800-995-4543 (Phone)
Use for services such as Adult Crisis Response, ARMHS, Diagnostic Assessment, Partial Hospitalization, and Psychotherapy services.
Member Name:
Member Address:
Member City, State, Zip:
Health Plan/Group Number:
Member Insurance ID Number:
Member DOB:
Is this treatment court-ordered?
Provider Name:
Degree/License Type:
Clinic Name:
Mailing Address:
Yes
No
(if yes, submit order & evaluation)
Frequency:
Date of most recent visit:
Number of sessions to date:
Date 1st Visit (present episode of
care):
Release of information for payer signed:
Yes
No
Release of information for PCP signed:
Yes
No
Release of information for other treating professionals
Yes
No
signed:
NA
Treatment Plan or Summary sent to member’s PCP
Member/Parent/Guardian refused consent for release to PCP
Member states they have no PCP
Current Symptoms
Mood
Sad
Elated
Hopeless
Low Energy
Poor Concentration
Angry
Appropriate
No Problem
Other:
Anxiety
Worry
Panic
Fearfulness
Compulsive
None
Other:
Thought
Delusions
Hallucinations
Disorganized Speech
Obsessive
Distractible
No Problems
Other:
Behavior
Aggressive
Disorganized Behavior
Hyperactive
Sleep Problems, describe:
Appetite Problems, describe:
Target Problems/Symptoms:
Diagnosis
Primary:
Secondary:
Mailing City, State, Zip:
Provider ID:
Clinic ID (if applicable):
Supervising Provider Name:
Supervising Provider ID:
Provider Phone:
Provider Fax:
Prior Treatment - # Episodes in Past Year
MH: Outpatient
Inpatient
PHP
IOP
CD
PHP
IOP
Outpatient
Inpatient
Outcome:
AMA discharge
Completed Treatment/still using
Completed Treatment/Sober
Active in CD Support Group
Yes
Risk Assessment
Suicidality:
None
Ideation
Plan
Intent w/o means
Intent with means
Truant
Compulsive
Runaway
Ideation in past year
Attempt in past year
Family /peer history of completed suicide
If risk exists: member has contracted not to harm:
Self
Others
Declined to contract
Homicidality:
None
Ideation
Plan
Other:
Intent w/o means
Ideation in past year
Intent with means
History Substance -- Abuse/Dependence
Assessed
Yes
No
If yes, drugs of choice:
Current abuse/dependence
Problem
Yes
No
By family/significant other
Other Risk Factors
Medical Conditions:
History physical/sexual abuse
Anorexia
Child/Elder neglect
Bulimia
Psychosocial and Environmental Problems
Economic
Housing
Occupational
Other psychosocial problems
Problems accessing health services
Problems related to interactions with legal/criminal system
Problems related to social environment/school
Goals: Expected Outcome and Prognosis
Return to normal functioning
Expect improvement, anticipate less than normal functioning
Relieve acute symptoms, return to baseline functioning
Maintain current status/prevent deterioration
page 1 of 2 pages
SCHA
SCHA # 2285 (1/2014)
Outpatient Mental Health Authorization
Member Name:
Member Insurance ID Number:
Treatment Objectives (List objectives directed at reducing symptoms and impairment in functioning.)
Progress Rating Scale: N–New Objective 1–Much
2 – Somewhat
3 – No Change
4 – Slight
5 – Great
Worse
Worse
Improvement Improvement
Measurable Objective
Intervention/Method(s) for achieving objective
Progress to Date
If child/adolescent: Is family involved:
Yes
No Explain:
Services/Code Number(s) Requested / Dates (Select code and complete unit/session and dates)
Adult Crisis Response:
Code/Modifier
# Unit /Session From:
To:
Code/ Modifier
# Unit/ Session From:
S9484
S9484 HN
S9484 HM
S9484 HQ
H0018
90882 HK
90882 HK HM
ARMHS:
H2017
H2017 HM
H2017 HQ
H2017 UD
H2017 UD HM
H0034
H0034 HQ
90882
90882 UD
90882 HM
90882 UD HM
Diagnostic Assessment:
90791
90792
Partial Hospitalization:
H0035
H0035 HA
Psychotherapy:
90832
90846
90833
90847
90834
90849
90836
90853
90837
90875
90838
90876
E/M , specify:
Interactive complexity, specify:
Other, specify:
Medications
Has member been evaluated for psychiatric medications within last 12 months?
Yes
No
Member refused
Prescribing M.D. Name:
List all current medications/dose:
Medication
Dose
Medication
Dose
Compliant with psychotropic as prescribed?
Signatures:
Provider’s Signature:
Yes
No
NA
Compliant with medical as prescribed?
Yes
R - Resolved
Resolution
Date
To:
No
NA
Date:
Supervisor’s Signature:
Date:
Member’s Signature:(If required)
Date:
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