Authorization Request Form

Use this form to request authorizations and reauthorizations for Still Waters Individuals.

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REQUESTED FOR:

Name – Requested FOR

REQUESTED BY:

Name – Requested by
Email – Requested by
List your email here to receive a notification of this submission.

CURRENT CLINICAL INFORMATION

ANXIETY DISORDERS

Obsessions/Compulsions
Generalized Anxiety
Panic Attacks
Phobias
Somatic Complaints
PTSD Symptoms

MANIA

Insomnia
Grandiosity
Pressured Speech
Poor Judgement / Impulsiveness

PSYCHOTIC DISORDERS

Delusuons / Paranoia
Self-Care Issues
Hallucinations
Disorganized Thought Process
Loose Associations

DEPRESSION

Impaired Concentration
Impaired Memory
Psychometer Retardation
Sexual Issues
Appetite Disturbance
Irritability
Agitation
Sleep Disturbance
Hopelessness / Helplessness

SUBSTANCE ABUSE

Lose of Control of Dosage
Amnesic Episode
Legal Problems
Alcohol Abuse
Opiate Abuse
Prescription Medication Abuse
Polysubstance Abuse
Other Drugs
Please list other drugs below.

PERSONALITY DISORDER

Oddness / Eccentricities
Oppositional
Disregard for the Law
Recurring Self Injuries
Sense of Entitlement
Passive Aggresive
Dependency

HISTORY

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ADDITIONAL INFORMATION

In the text boxes provide details regarding current need for treatment and the behavior during the last 30 days that support the service requested.
Current / Hx of SI and HI that cause concern for safety, welfare and wellness of the member
Ability to meet basic needs, fulfill usual role, and maintain health and wellness
Symptoms and Tx for medical/SUD diagnosis in addition to primary Hx
Stress in the environment such as home, school, and work that interfere with the member’s wellbeing
Personal associations and relationships in the community that enhance the quality and security of the member
Acceptance and engagement

MEDICATIONS

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Member Complaint w/ Medications 1

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Member Complaint w/ Medications 2

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Member Complaint w/ Medications 3

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Member Complaint w/ Medications 4