Service Request Application (SRA) for:

OUTPATIENT TREATMENT
CONTINUED STAY REQUEST

ALL ITEMS ARE REQUIRED

After response is entered, use the Tab key to advance to next item.
 
MEMBER INFORMATION PROVIDER INFORMATION
Member First Name       Provider Name      
Member Last Name       Clinical Contact Name      
Medicaid Number       Provider MIS#      
Member Date of Birth       Provider Tax ID#      
Provider NPI      
Sex Male Female Provider Phone      
Provider Email      
Member Address       Service Address      
City, State & Zip Code       City, State & Zip Code      

Procedure Code
Primary Diagnosis   
Secondary Diagnosis   
Requested Start Date   
CLINICAL INFORMATION
90832 Psychotherapy 30 min 90833 30 min Psychotherapy (add-on code)
90834 Psychotherapy 45 min 90836 45 min Psychotherapy (add-on code)
90837 Psychotherapy 60 min 90838 60 min Psychotherapy (add-on code)
90846 Family Therapy w/o member 90847 Family therapy member present
90853 Group Therapy, Not Multiple Family
   
   
   

1. Is this a Retro Review:   Yes No  Date notified of Medicaid eligibility:       

2. Are services primarily for Mental Health (MH), Substance Abuse (SA), or both?  MH     SA    Both

3. Date Initial Plan of Care signed (MM/DD/YYYY):      

4. Was a psychosocial assessment completed? Yes No

5. Have you previously submitted a TRF (Concurrent Auth) request for this individual? Yes No

6. Is this an EPSDT request for extension beyond the 26 annual sessions? Yes No

7. Confirm Substance Abuse and/or Medication evaluations completed, if needed: Yes No N/A

8. Is this individual on a medication prescribed by you or another practitioner to treat this condition? Yes No
a. If yes, please list the medications:      

9. Symptoms and behaviors indicate need for continued outpatient treatment: Yes No

Revised 06/03/2016 ®Magellan Healthcare, Inc. Page 1 of 2

10. Has the individual expressed suicidal ideation in the last 30 days?  Yes    No
a. If yes, what is the safety plan?      

11. Has individual received treatment besides outpatient therapy or medication management?   Yes   No
a. If yes, which services?      

12. Individual has shown:    No progress   Minimal progress Moderate progress Significant progress

Revised 06/03/2016 ®Magellan Healthcare, Inc. Page 2 of 2