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Authorization Request
Requested Services Header
Requested Start Date
11/12/2009
Level of Service
MM - MEDICATION MANAGEMENT
Type of Service
MEDICATION MANAGEMENT
Level of Care
O - Outpatient
Admit Date
11/12/2009
Authorization#
111109-1-38
Client Authorization #
N/A
Type of Request
CONCURRENT
Submission Date
Member Name
SMITH JOHN
Member ID
56462084401
DOB
12/07/1944
 
 
 
 
 
 
Provider Name
JONES BARRY
Provider ID
018599
Vendor ID
A099987
TIN
581279778
 
 
 
 

Diagnosis

Axis I

Axis II
* Diagnosis Code 1
290.20
Description
SENILE DEMENTIA WITH DELUSIONAL FEATURES
Diagnosis Code 1
Description
Diagnosis Code 2
Description
Diagnosis Code 2
Description
Diagnosis Code 3
Description
Diagnosis Code 3
Description

Axis III

Axis IV
Diagnosis Code 1
Diagnosis Code 2
Diagnosis Code 3
Check all that apply
N- None N- Problems with access to health care services
N- Educational problems N- Problems related to interaction w/legal system/crime
N- Financial problems N- Problems with Primary support group
N- Housing problems N- Problems related to the social environment
N- Occupational problems N- Unknown
N- Other psychosocial and environmental problems  

Axis V
Current GAF Score     UK
Highest GAF Score in the Past Year    
Current CGAS Score    
Highest CGAS Score in the Past Year    
Overall Severity of Psychosocial Problems
Course of Illness
All fields marked with an asterisk (*) are required.
 
Requested Services
 
Current Benefit Year Authorization ( - )
 
*Place of Service *CPT or HCPC Code *Modifier 1 (If Applicable) *Visits/ Units
AMBULANCE
0