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Clinical Form – Husky Authorization
Chris Obara
2022-04-25T17:49:58+00:00
HUSKY AUTHORIZATION FORM
Clinicians are required to complete this form whenever an authorization is required for a client that they treat with Husky insurance.
Authorization Type Required
*
New Authorization
Re-Authorizatiom
Existing Patient Prior to Authorization?
*
Yes
No
Clinician Assigned to Client
*
Alexandra Rovello
Alexis Phillips
Amy Albero
Annemarie Carpenter
Arielle Kempler
Audra Antoniello
Betty Hechavarria
Briana Zuccarelli
Brittany King
Carli King
Carly Carbone
Carrie Berlepsch
Chey Johnson
Cindy Serrano
Daniela Trotman
Debbie Steckler
Destiny Elliott
Elise McCandless
Elisabeth DiDonato
Emma Cianci
Jacqueline Fidelman
Jessica Cunningham
Jessica Desai
Julinda Velmishi
Kaila Zeigler
Kathleen Nash
Martine Bruno
McKenzie Williams
Mataya Robertson
Megan Young
Melissa Weidner
Michelle Morris
Nicole Pradella
Sara Baigorri
Symone McCullers
Thea Haley
Husky ID
*
CLIENT INFORMATION
Client First Name
*
First Last Name
*
Client Date of Birth
*
Gender
*
Male
Female
Other
REFERRAL INFORMATION
Original Referral Source
*
Revive Referral (See Intake Notes)
Community Collaboration
Court-Ordered/Legal
CT BHP ASO
DCF
DDS
DMHAS
EMPS
Hospital Emergency Department
Medical ASO
Other
Other BH Provider
PCP / Medical Provider
School
Self/Family Member
Step Down Inpatient/Intermediate Loc
Referral Type
Routine
Urgent
Emergent
First Contact Method
*
Revive Referral (See Intake Notes)
Telephone
Walk-In
Date of First Contact
*
Date of First Appointment Offered
*
Date of First Appointment Accepted
*
Date of First Clinical Evaluation
*
Number of No Shows/Late Cancels Prior to Intake
BEHAVIORAL DIAGNOSES
Diagnostic Code 1
*
Diagnostic Code 2
Diagnostic Code 3
Diagnostic Code 4
SOCIAL ELEMENTS IMPACTING DIAGNOSIS (Check All That Apply)
Social Elements Impacting Diagnosis
*
None
Educational Problems
Financial Problems
Medical Disabilities (Must be Accommodated for in Treatment)
Problems Accessing Health Care Services
Problems with Interacting with Legal Services
Problems with Primary Support Group
Housing Problems (Not Homeless)
Occupational Problems
Problems Related to Social Environment
Homeless
Unknown
Other Psychological and Environmental Problems
If Other, describe
FUNCTIONAL ASSESSMENT
Assessment Measure
*
CDC HRQOL
CGAS
FAST
GAF
Other
OMFAQ
SF12
SF36
WHO DAS
Assessment Score
*
Secondary Assessment Measure
CDC HRQOL
CGAS
FAST
GAF
Other
OMFAQ
SF12
SF36
WHO DAS
Secondary Assessment Score
CURRENT RISKS
Member's Risk to Self
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Member's Risk to Others
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
CURRENT IMPAIRMENTS
Mood Disturbances (Depression or Mania)
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Weight Change Associated with Behavioral Diagnosis
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Anxiety
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Medical/Physical Conditions
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Psychosis/Hallucinations/Delusions
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Substance Use/Dependence
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Thinking/Cognition/Memory/Concentration Problems
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Job/School Performance Problems
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Impulsive/Reckless/Aggressive Behavior
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Social Functioning/Relationships/Marital/Family Problems
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Activities of Daily Living Problems
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Legal
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Impairments Related to Loss/Trauma
*
0-None
1-Mild or Mildly Incapacitating
2-Moderate or Moderately Incapacitating
3-Severe or Severely Incapacitating
N/A
Does Member have a co-occurring mental health and substance use conditions?
*
Yes
No
Not Assessed
SPECIAL POPULATIONS - (Complete if Client age is 0 - 18)
Living Situation
Crisis Stabilization Residential
Foster Care (Standard)
Foster Care (Therapeutic or Professional)
Group Home
Homeless
Independent Living w/Supports
Jail/Correctional Facility
Private Residence
Psychiatric Residential Treatment Facility
Residential Treatment Center
Safe Home
Shelter
Severely Emotionally Disturbed
Yes
No
Unknown
Co-occurring Disorder
Yes
No
Unknown
Within last 12 months has the child/youth been arrested?
Yes
No
Unknown
Within last 12 months has the child/youth been expelled?
Yes
No
Unknown
During 90 days prior to this request for re-authorization has:
Member been enrolled in school?
Yes
No, Graduated
No, Expelled
No, Dropped Out
If enrolled in school, has member been suspended?
Yes
No
If enrolled in school, does member have unexcused attendance problems?
Yes
No
Unknown
Member's behavior resulted in new legal problems?
Yes
No
Unknown
Any new legal charges brought against member?
Yes
No
Unknown
Family member been involved in any peer support activities
Yes
No
Unknown
Member been actively involved in any organized recreation activities?
Yes
No
Unknown
Does care plan include involvement in organized recreation activities?
Yes
No
Unknown
During the past 3 months have you communicate with any of the following regarding the treatment of member:
School
Yes
No
Child Note Enrolled in School
DCF
Yes
No
Child Not DCF Involved
Probation/Parole
Yes
No
Child Not Involved with Probation/Parole
PCP
Yes
No
TREATMENT PLAN
Is psychiatric medication evaluation or medication management visit indicated?
*
Yes
No
Have you provided information regarding Peer Support or Self Help Options?
*
Yes
No
Do family members of significant others actively participate in treatment?
*
Yes
No
If Yes, are any family members/significant others receiving their own MH or SA treatment?
Yes
No
Have you obtained consent to contact:
School
*
Yes
No
Denied
Adult Not Attending School
Medical Provider
*
Yes
No
Denied
N/A
Previous Behavioral Health Provider
*
Yes
No
Denied
Treatment Plan was developed with member and has measurable goals?
*
Yes
No
Does a documented goal oriented treatment plan exist?
*
Yes
No
Anticipated Date for Achievement of Current Treatment Plan Goals
*
RE-REGISTRATION ONLY
Indicated the Degree of Progress from previous registration
*
None
Minimal
Moderate
High
Treatment modalities to be used for this request
Family?
Yes
No
Family Frequency
Weekly
Monthly
Quarterly
Other
Individual?
Yes
No
Individual Frequency
Weekly
Monthly
Quarterly
Other
Group?
Yes
No
Group Frequency
Weekly
Monthly
Quarterly
Other
Medication Management?
Yes
No
Medication Management Frequency
Weekly
Monthly
Quarterly
Other
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