Admit date: 1-WM 2-WM 3.2-WM 3.7-WM 4-WM DSM-V diagnoses: Please list all diagnoses (psychiatric, chemical dependency and medical)

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1 Substance Use Disorder Withdrawal Management Prior Authorization and Continued Care Request (Use for American Society of Addiction Medicine [ASAM] withdrawal management levels of care) To avoid delays in processing, please fill this form out completely and fax to Amerigroup Washington, Inc. at If you have any questions, please contact Provider Services at Member information Name: Amerigroup ID: Date of birth: Address: City: State: ZIP code: Provider information Facility name: Facility NPI/TIN: Facility address: Office contact: Phone: Fax: Provider name: Provider NPI: ASAM level of care: Admit date: 1-WM 2-WM 3.2-WM 3.7-WM 4-WM DSM-V diagnoses: Please list all diagnoses (psychiatric, chemical dependency and medical) Current risk factors Suicide None Ideation Intent without means Intent with means Contracted not to harm self Homicide None Ideation Intent without means Intent with means Contracted not to harm others Physical or sexual abuse or child/elder neglect: If yes, patient is: Victim Perpetrator Both Neither, but abuse exists in family WAPEC September 2018

2 Current risk factors Explain any significant history of suicidal, homicidal, impulse control or other behavior that may impact the patient s level of functioning: Job/school Housing Legal issues Family history of mental illness or substance abuse Abuse has been legally reported: Abuse or neglect involving a child or elder: Risk history Page 2 of 6

3 Vital signs Date Time BP Respiration Pulse Temp ASAM dimensions I: Intoxication/withdrawal potential Alcohol withdrawal CIWA score: BAL Breathalyzer results Withdrawing from other substances? If yes, provide all currently used substances: History of blackouts? History of seizures? History of DTs? Current withdrawal symptoms Tremor (shakes) Agitation Sweating Tachycardia Craving for alcohol Irritability Disorientation Hypertension Anxiety Loss of appetite Visual hallucinations Fever Insomnia Vomiting Auditory hallucinations Seizure Vivid dreams Headache Tactile hallucinations Opioid withdrawal (select the category which best describes the current symptoms) COWS score: Occasional yawning, slight pupillary dilation, rhinorrhea, chills, mild anxiety Frequent yawning, piloerection, abdominal cramps, nausea, loose stools, body aches, mild elevation of BP or pulse, mod sweating, anxiety, tremulousness, restlessness, irritability Vomiting, diarrhea, observable tremor, mild fever, mod elevation in BP or pulse, significant anxiety, sweating, restlessness, body aches, pupillary dilation, piloerection Debilitating vomiting and diarrhea, agitation, gross tremor, fever, severe elevation of BP or pulse II. Significant active co-occurring physical health conditions? II. Significant active co-occurring behavioral health conditions? Page 3 of 6

4 ASAM dimensions III. Comprehension III. Ability to understand and follow treatment recommendations? Awake Alert Knows name Knows location Knows date Good Fair Poor IV. Level of cooperation? IV. Commitment to WD management process? V. Imminent risk of relapse? Cooperative Sometimes cooperative Uncooperative Committed Questionable Low commitment VI. Support from family/friends/community? Strong support Moderate support Poor support Medications (optional for nonphysicians): Current medications Dosage Frequency Patient s treatment history, including all levels of care: Mental Date of last health level episode/session of care Number of distinct episodes/ sessions Substance Use Disorder (SUD) level of care Number of distinct episodes /sessions Date of last episode/ session Inpatient mental health Inpatient/RTC SUD Page 4 of 6

5 Patient s treatment history, including all levels of care: PHP mental health PHP SUD IOP mental health IOP SUD Outpatient mental health Outpatient SUD Withdrawal management/detox Treatment goals Objective outcome criteria by which goal achievement is measured Discharge plan (SUD, BH, PCP appointments, housing, community supports) Expected outcome and prognosis Return to normal functioning Expect improvement, anticipate less than normal functioning Relieve acute symptoms, return to baseline functioning Maintain current status, prevent deterioration Page 5 of 6

6 Number of days: Provider signature: Phone: Estimated discharge date: Date: Fax: Disclaimer: Authorization indicates that Amerigroup determined medical necessity has been met for the requested service(s) but does not guarantee payment. Payment is contingent upon the eligibility and benefit limitations at the time services are rendered. Page 6 of 6