Clinicians are required to complete this form whenever an authorization is required for a client that they treat with Husky insurance.
Authorization Type Required
Existing Patient Prior to Authorization?
Mood Disturbances (Depression or Mania)
Weight Change Associated with Behavioral Diagnosis
Job/School Performance Problems
Social Functioning/Relationships/Marital/Family Problems
Activities of Daily Living Problems
Impairments Related to Loss/Trauma
Does Member have a co-occurring mental health and substance use conditions?
SPECIAL POPULATIONS - (Complete if Client age is 0 - 18)
Severely Emotionally Disturbed
Within last 12 months has the child/youth been arrested?
Within last 12 months has the child/youth been expelled?
During 90 days prior to this request for re-authorization has:
If enrolled in school, has member been suspended?
If enrolled in school, does member have unexcused attendance problems?
Member's behavior resulted in new legal problems?
Any new legal charges brought against member?
Family member been involved in any peer support activities
Member been actively involved in any organized recreation activities?
Does care plan include involvement in organized recreation activities?
During the past 3 months have you communicate with any of the following regarding the treatment of member:
Have you obtained consent to contact:
Treatment Plan was developed with member and has measurable goals?
Does a documented goal oriented treatment plan exist?
Treatment modalities to be used for this request