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

Clinician Assigned to Client *

Husky ID *

CLIENT INFORMATION

Client First Name *

First Last Name *

Client Date of Birth *

Gender *

REFERRAL INFORMATION

Original Referral Source *

Referral Type

First Contact Method *

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 *

Assessment Score *

Secondary Assessment Measure

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

Not Assessed

SPECIAL POPULATIONS - (Complete if Client age is 0 - 18)

Living Situation

Severely Emotionally Disturbed

Yes

Unknown

Co-occurring Disorder

Yes

Unknown

Within last 12 months has the child/youth been arrested?

Yes

Unknown

Within last 12 months has the child/youth been expelled?

Yes

Unknown

During 90 days prior to this request for re-authorization has:

Member been enrolled in school?

If enrolled in school, has member been suspended?

Yes

If enrolled in school, does member have unexcused attendance problems?

Yes

Unknown

Member's behavior resulted in new legal problems?

Yes

Unknown

Any new legal charges brought against member?

Yes

Unknown

Family member been involved in any peer support activities

Yes

Unknown

Member been actively involved in any organized recreation activities?

Yes

Unknown

Does care plan include involvement in organized recreation activities?

Yes

Unknown

During the past 3 months have you communicate with any of the following regarding the treatment of member:

School

DCF

Probation/Parole

PCP

TREATMENT PLAN

Is psychiatric medication evaluation or medication management visit indicated? *

Yes

Have you provided information regarding Peer Support or Self Help Options? *

Yes

Do family members of significant others actively participate in treatment? *

Yes

If Yes, are any family members/significant others receiving their own MH or SA treatment?

Yes

Have you obtained consent to contact:

School *

Medical Provider *

Previous Behavioral Health Provider *

Treatment Plan was developed with member and has measurable goals? *

Yes

Does a documented goal oriented treatment plan exist? *

Yes

Anticipated Date for Achievement of Current Treatment Plan Goals *

RE-REGISTRATION ONLY

Indicated the Degree of Progress from previous registration *

Treatment modalities to be used for this request

Family?

Yes

Family Frequency

Weekly

Monthly

Quarterly

Other

Individual?

Yes

Individual Frequency

Weekly

Monthly

Quarterly

Other

Group?

Yes

Group Frequency

Weekly

Monthly

Quarterly

Other

Medication Management?

Yes

Medication Management Frequency

Weekly

Monthly

Quarterly

Other

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