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Chemical Dependency Request Worksheet

MMSI 4001 41st Street NW Rochester, Minnesota 55901-8901 MMSI Chemical Dependency 1-800-645-6296 1-888-889-7822 (fax)

Non-Participating Provider

Member Name Member Insurance ID Number Diagnosis Assessment Completed By Credentials Agency Birth Date (Month DD, YYYY) Service Date (Month DD, YYYY)

Yes Yes

No No

Are you requesting an authorization for the CD Assessment? Are you requesting pre-approval for Residential CD treatment? (If so please submit CD assessment) Facility being considered: __________________________________________________________________________ Anticipated date of admission: ______________________________________________________________________

Yes Yes

No No

Are you requesting CD treatment for IOP/OP CD treatment? (If so submit the Minnesota Universal Form) Court Ordered? Please submit copy of court order to MMSI Phone Fax

Person making request

MMSI Use Only

Meets ASAM Criteria for requested level of care: Yes No If yes, please have admitting facility contact MMSI upon admission. Provider notified by: Fax ______________________________ Completed By Phone _________________________________ Date (Month DD, YYYY) Authorization number for the CD Assessment

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. Payment is also subject to national and industry coding and billing standards. Plan coverage must be in effect for the member at the time services are rendered.

©2008 Mayo Foundation for Medical Education and Research

MC0684-95rev1208

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