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Behavioral Health Service Request Form
Substance Abuse, Detox and Residential Treatment Medicaid
Call for Recertification of Admissions: 18556201861
Kentucky Medicaid Fax: 18773383686
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How to fill out behavioral health service request
How to fill out behavioral health service request
01
Obtain a behavioral health service request form from your primary care provider or insurance company.
02
Fill out all necessary personal information such as name, address, date of birth, and insurance information.
03
Provide detailed information about your symptoms or mental health concerns.
04
Indicate the type of services you are requesting (therapy, medication management, etc.)
05
Sign and date the form to confirm your consent for treatment.
06
Submit the completed form to the appropriate party for review and approval.
Who needs behavioral health service request?
01
Individuals who are experiencing mental health issues or behavioral health concerns that require professional assessment and treatment.
02
Those who have been recommended for further evaluation by their primary care provider or mental health professional.
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What is behavioral health service request?
A behavioral health service request is a formal document submitted to request services related to mental health or substance abuse.
Who is required to file behavioral health service request?
Anyone seeking services for mental health or substance abuse needs to file a behavioral health service request.
How to fill out behavioral health service request?
To fill out a behavioral health service request, one needs to provide personal information, details of the requested services, and any relevant medical history.
What is the purpose of behavioral health service request?
The purpose of a behavioral health service request is to request services related to mental health or substance abuse treatment.
What information must be reported on behavioral health service request?
Information such as personal details, insurance information, requested services, medical history, and any relevant documentation must be reported on a behavioral health service request.
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