Authorization Request Form

Use this form to request authorizations and reauthorizations for Still Waters Individuals.
  • Date Format: MM slash DD slash YYYY
  • Requested for:

  • Requested by:

  • CURRENT CLINICAL INFORMATION

  • Anxiety Disorders

  • Mania

  • Psychotic Disorders

  • Depression

  • Substance Abuse

    Please list other drugs below.
  • Personality Disorder

  • HISTORY

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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  • Date Format: MM slash DD slash YYYY
  • 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

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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