plantilla para solicitar una primera evaluacion inicial
PRE-AUTHORIZATION REQUEST: INITIAL MENTAL HEALTH EVALUATION
Section 1: Patient & Insurance Information
Patient’s Full Name:
Date of Birth:
Full Address:
Insurance Policy #:
Member/Subscriber ID:
Section 2: Provider Information
Clinical Group Name:
NPI (Type 2):
Tax ID (TIN/EIN):
Administrative Contact:
Group Phone & Fax:
Section 3: Service Request Details
Information Provided By (Clinician):
Date of Initial Contact:
Requested Service (CPT Code):
Provisional Diagnosis:
Referring Provider (if any):
Section 4: Medical Necessity Justification
Presenting Problem / Reason for Consultation:
Current Symptomatology and Severity (Use bullet points for clarity):
Functional Impact (How symptoms affect daily life, work, social activities, etc.):
Relevant History (Previous MH treatment, medical history, trauma):
Section 5: Authorization and Consent
Authorization Status:
Status: GRANTED
By explicit digital signature, the client has authorized the release of information necessary for this evaluation request. This consent is verifiable through a digital audit trail and can be modified or revoked by the client at any time via their secure personal portal. Any changes are processed by our system automatically and take effect immediately, ensuring the client maintains full control over their permissions.