Last Name First Name MI Birth Date (MM, DD, YYYY)

Member ID Number (shown on membership card) Provider/Physician Name Facility Name

Facility Address City State Zip

NPI Number Tax ID Number Current Authorization Number

Current Days Authorized Expected Discharge Date Additional Days Requested

Current Diagnosis

Current Active Treatment Plan

Status of Goals in the Individual Treatment Plan To-Date

Suicidal/Homicidal/Self Injury Present? Yes No

If Yes, is patient currently under SI/HI monitoring? Yes No How often? ___________________

Any Court Intervention? Yes No If yes, attach copy of court order with this request.

Next Scheduled Court Date ___________________Targeted Symptoms and Behaviors of Concern/Interventions

Discharge Plan (Identify steps taken toward discharge plan)

Utilization Review Coordinator Phone Fax

Mental Health Admit Residential Eating Disorder Residential Partial Hospitalization (see below) Intensive Outpatient (see below)

Mayo Clinic Health Solutions Behavioral HealthPO Box 211698Eagan, MN 55121Phone: 1-800-645-6296Fax: 1-888-889-7822

Mental Health Concurrent Review

Instructions: Complete this form in its entirety and submit to Mayo Clinic Health Solutions by mail or fax using the con-tact information listed above. Be sure to include current clinical documentation with the form.

Prior authorization or predetermination confirms medical necessity only and does not guarantee payment. Payment is determined at the time the claim is received and is subject to health plan exclusions and out-of-network benefits. Plan coverage must be in effect for the member at the time services are rendered.

111-MMS317 (02/17)©2017 Mayo Foundation for Medical Education and Research

If you checked Partial Hospitalization or Intensive Outpatient, above, provide the following information.Dates of Service (MM, DD, YYYY) ______________ to ______________ Number of Days per Week _________ Hours per Day _________Billing Code (if requesting Intensive Outpatient)

Additional Details