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PRIOR AUTHORIZATION INITIAL BEHAVIORAL HEALTH CONTACT AND TRIAGE REQUEST PERSON COMPLETING AND SUBMITTING THIS FORM: Name: Facility: Phone: Fax: Date form Submitted: MEMBER INFORMATION: Member Name:

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What is person completing and submitting?

Person completing and submitting refers to the individual responsible for filling out and submitting a specific form or document.

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The person completing and submitting is typically the one who has the necessary information and authority to accurately fill out the form.

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The person completing and submitting should carefully review the instructions provided with the form and accurately enter all required information.

What is the purpose of person completing and submitting?

The purpose of the person completing and submitting is to ensure timely and accurate submission of the form to the appropriate authority.

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The person completing and submitting must report all relevant and required information as specified in the form.

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