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Employee Assistance Network, Inc. REQUEST FOR ADDITIONAL SERVICES Please complete this form and return to Employee Assistance Network, Inc. in advance of the last authorized session / day. This will enable us to authorize additional sessions, as appropriate, without interrupting therapy. The plan is not obligated to reimburse any charges made without prior authorization. Client Name: _____________________________ SS #: _______________________ Client Current Address / Phone: ___________________________________________ Provider Name: _____________________________ Phone #: _________________ The intent of the benefit plan is that services should be designed to restore functions of the client as quickly as possible. Identify Target Symptoms:
Measurable Treatment Goal:
______________________________________
_____________________________________
________________________________________
_____________________________________ DSM Code: _________________
Diagnosis: _________________________________________ Service Type 1. Initial Evaluation -- 90801 4. Intensive Outpatient -- 90853 2. Individual Psychotherapy -- 90806/07 5. Medication Check -- 90862 3. 30 Minute Indiv. Psychotherapy --
90804/05
6. Group Psychotherapy -- 90853 Proposed frequency of session (biweekly, monthly, etc.): ___________________________________ Projected date for conclusion of this case: _______________________________________________
__________________________________________ __________________________ Employee Assistance Network, Inc. • Doctor’s Park Ste. 3-C • 417 Biltmore Avenue • Asheville, NC 28801• Phone: (828) 252-5725 Fax: (828) 258-1336 (01/2010) |