Behavioral Health Outpatient Psychotherapy
Authorization Form
Today’s date
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Fax to: 888-977-0776
For Tufts Health Unify, fax to: 781-393-2607
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Behavioral health outpatient psychotherapy requires prior authorization after 12 visits per member per benefit year.
To ensure a timely response to your request, please submit this completed form one to three weeks prior to the
member’s last covered visit. Submission of this form does not guarantee authorization of your request.
Member information
Member name
Member ID #
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DOB
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Provider information
Provider name
NPI #
Provider phone
Provider address
City
Contact name
How long has the member been in treatment with this provider?
Agency/Group involvement
AA/NA
Court
DMH
DCF
DYS
DDS
Agency name
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Provider fax
State
Contact phone
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to
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ZIP
Ext
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Diagnosis Please reference DSM codes.
EAP
Family
Friends
Religious group
Spouse/Partner
Other
Axis I
Axis II
Axis III
Axis IV
Axis V
Requested services Please complete this table to indicate your current request for the next three months’ sessions using
Current Procedural Terminology (CPT) codes and appropriate modifiers (if applicable).
Date range of requested sessions from
Code
90791
90832
90834
90846
90847
90849
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Sessions
# of sessions requested
Psychiatric diagnostic evaluation (no medical services)
Individual psychotherapy, 20 ‒ 30 minutes
Individual psychotherapy, 45 minutes
Family psychotherapy without patient present
Family psychotherapy with patient present
Multifamily group therapy
Current medications and treatment
Please list current psychotropic medications and dosages, if applicable.
Please indicate the other providers involved in the member’s care.
Group therapist
PCP
Psychiatrist
Specialist
Therapist
CBHI provider
If the patient is younger than 18, describe how the parent/guardian is involved in treatment.
CSP
Assessment
Has the member received a higher level of care in the last year (e.g., inpatient)?
If yes, specify level of care and number and date(s) of admission(s).
5308E 07295
Yes
Form available at tuftshealthplan.com/providers
Page 1 of 2
No
Phone: 888-257-1985
Behavioral Health Outpatient Psychotherapy
Authorization Form
Fax to: 888-977-0776
For Tufts Health Unify, fax to: 781-393-2607
Member name
Member ID#
Please indicate risk of psychiatric hospitalization. (low)
If 3, 4, or 5, please explain.
1
2
3
4
5 (high)
Please select the ONE symptom that best applies to the member.
Anxiety
Disruptive behavior
Mania or hypomania
Recklessness or impulsivity
Depression or irritability
Eating disorder
Psychosis
Substance abuse
Please provide details for the selected symptom. For substance use, please specify the substance used, amount, frequency,
duration, and intensity of cravings.
Please indicate member’s functioning level over the course of the last five visits. Check all that apply.
Decreased productivity at school or work
Warning/suspension at school or work
Decreased social contact
Subject of complaints registered with the authorities
Increased school detentions or lower grades
School or work absence of at least two days per month due
to psychiatric symptoms
Difficulty respecting limits set by others
Difficulty in caring for dependents
Leave of absence due to psychiatric disorder
Difficulty with activities of daily living
Stabilized on medication
Easily frustrated
Other
Argumentative or verbally hostile
Which of the following behaviors has the member exhibited in the last three months? Check all that apply.
Family violence
Firesetting
Physical/sexual assault
Coping with loss
Self-mutilation
For self-mutilation, specify frequency and severity.
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Homicide
Not present
Ideation
Plan
Means
Prior attempt
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Suicide
Not present
Ideation
Plan
Means
Prior attempt
Has the member attended at least four (three, if adolescent) of their last five sessions?
Yes
No
If no, please indicate why.
Have the member’s symptoms improved with treatment?
Behavioral symptoms
Much worse
Worse
No change
Better
Much better
Ability to perform major activities
Much worse
Worse
No change
Better
Much better
If requesting weekly therapy, please describe the steps that will allow your patient to transition to biweekly or monthly sessions.
Goals Please tell us about the member’s most significant goals since beginning treatment.
Goal
Progress achieved
Barriers to progress
Additional comments or information
5308E 07295
Form available at tuftshealthplan.com/providers
Page 2 of 2
Phone: 888-257-1985