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Online Pre-Authorization Form

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Name
MM slash DD slash YYYY
Parent/Legal Guardian Name:
Gender:
Address
If Medicare, please complete the following questions below:
Criteria for PRP Uninsured/ State Funded Coverage Questions
Recently Incarcerated?
Hospitalized for mental health within the last 6 months?
Placed in a state hospital?
A RRP (Residential Rehabilitation Service) Bed within the last 6 months?
Type of Care (PLEASE CHECK ALL THAT APPLY, if qualified):
Any arrest in the past 30 days?
Currently Employed?
Veteran?
In Iraq or Afghanistan?
Is the client eligible for MTA pass?
Any restrictions from referring agency (i.e., mobile therapy, on blackout, no telemedicine, etc.)?
Is the client on parole or probation?

Office Use Only:

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