Montana Medicaid Youth Continued Stay Request Authorization Form Psychiatric Residential Treatment Facility (PRTF) Please type or print clearly. Processing may be delayed if information submitted is illegible or incomplete. (124) PRTF Services Request Submitted By It is recommended that a licensed or a supervised in-training mental health professional complete the authorization request, however it is not required. NAME: LAST RN LCSW LPC/LCPC Licensed Psychologist MD Other: CREDENTIALS: EXT: Information NAME: MEDICAID NUMBER: ADMIT DATE: SSN: Responsible Party who receives determination notification (List CPS worker or probation officer when applicable.) PHONE NAME: ADDRESS: CITY: STATE: ZIP: Parents Government Agency Other Relative: RELATIONSHIP TO Responsible party is the person authorized to consent for medical treatment. Facility Information NAME: ADDRESS: CITY: STATE: ZIP: PHONE NUMBER: FAX NUMBER: PROVIDER NUMBER: NPI NUMBER: TAXONOMY: NUMBER OF DAYS REQUESTED: START DATE: Clinical Information ANY CHANGES IN DSM V DIAGNOSIS: CODE:
Montana Medicaid Youth Continued Stay Request Authorization Form Psychiatric Residential Treatment Facility (PRTF) Please type or print clearly. Processing may be delayed if information submitted is illegible or incomplete. (124) PRTF Services Request Submitted By It is recommended that a licensed or a supervised in-training mental health professional complete the authorization request, however it is not required. LAST NAME: CREDENTIALS: RN LCSW LPC/LCPC Licensed Psychologist MD Other: EXT: Information NAME: ADMIT DATE: SSN: Responsible Party who receives determination notification (List CPS worker or probation officer when applicable.) NAME: PHONE NUMBER: ADDRESS: CITY: STATE: ZIP: RELATIONSHIP TO Parents Government Agency Other Relative: Responsible party is the person authorized to consent for medical treatment. Facility Information NAME: ADDRESS: CITY: STATE: ZIP: PHONE NUMBER: FAX NUMBER: PROVIDER NUMBER: NPI NUMBER: TAXONOMY: NUMBER OF DAYS REQUESTED: START DATE: Clinical Information ANY CHANGES IN DSM V DIAGNOSIS: CODE: MEDICAID