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Get the free Outpatient/Inpatient Behavioral Health Service Authorization Request Form. Outpatien...

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Submit to: Coordinated Care Utilization Management Department 1145 Broadway, Suite 300 Tacoma, WA 98402 PHONE: 18776444613 FAX: 18332861086OUTPATIENT/ INPATIENT BEHAVIORAL HEALTH SERVICE AUTHORIZATION
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01
Gather personal information: Full name, date of birth, and contact information.
02
Provide insurance details: Include policy number and provider information.
03
Fill out medical history: List any previous mental health diagnoses and treatments.
04
Describe current symptoms: Be specific about feelings, behaviors, and any crises.
05
Provide emergency contacts: Include names and phone numbers of individuals to reach in case of an emergency.
06
Complete consent forms: Sign necessary documents for treatment and information sharing.

Who needs outpatientinpatient behavioral health service?

01
Individuals experiencing mental health issues such as depression, anxiety, or PTSD.
02
People in crisis or who have thoughts of self-harm or harming others.
03
Those needing support during transitional life events, such as divorce or loss.
04
Individuals struggling with substance abuse or addictive behaviors.
05
Patients with chronic mental health conditions seeking ongoing support.
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Outpatient/inpatient behavioral health service refers to mental health and substance use treatment delivered to patients either who stay in a facility (inpatient) or come in for treatment sessions without an overnight stay (outpatient).
Providers of outpatient and inpatient behavioral health services, including hospitals, clinics, and individual practitioners, are typically required to file the necessary documentation for these services.
To fill out outpatient/inpatient behavioral health service documentation, providers should include patient identification information, the type of service provided, date of service, diagnosis codes, and relevant treatment details.
The purpose of outpatient/inpatient behavioral health service is to provide necessary care for mental health and substance use disorders, improve patient well-being, and facilitate recovery through structured treatment options.
Reported information should include patient demographics, service dates, diagnosis codes, treatment plans, and any other relevant clinical information as required by regulatory bodies.
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