Referral Form

Initial Authorization & Concurrent UR Form

Phoenix Connections – IOP

401 Clairborne Road
Olathe, Kansas 66062
Referrals By Phone: (913) 324-3658
Referrals By Fax: (913) 768-1437

PERSONAL INFORMATION

INSURANCE INFORMATION



AUTHORIZATION TYPE

REFERRAL INFORMATION

Note that for all of the following questions, the likelihood of an authorization is improved when specific examples of the behaviors are provided.

RISK











FUNCTIONING






CO-MORBIDITY



RECOVERY ENVIRONMENT



RESILIENCY & TREATMENT HISTORY






ACCEPTANCE & ENGAGEMENT IN TREATMENT





FOR UTILIZATION REVIEW PURPOSES ONLY