Case Management Enrollment Form



REQUEST TO CHANGE AUTHORIZATION TO ANotHER CASE MANAGER

(FOR CLIENTS WHO HAVE A PRIOR AUTHORIATION NUMBER (PAN)

AND NEED TO CHANGE CASE MANAGERS WITHIN THE SAME AGENCY)

|CLIENT NAME: |      |MEDICAID NUMBER: |      |

| |

|CURRENT AUTHORIZATION INFORMATION |

|CURRENT PAN |EFFECTIVE DATE OF PAN |EXPIRATION DATE OF PAN |TPI ON CURRENT PAN |CURRENT INDIVIDUAL NPI |

|      |      |      |      |      |

|AUTHORIZED SERVICES: |

|# COMPREHENSIVE VISITS |# FACE-TO-FACE FOLLOW-UP VISITS |# TELEPHONE FOLLOW-UP VISITS |

|      |      |      |

|REQUESTED CHANGE |

|REASON FOR CHANGE IN CASE MANAGER: |

|CLIENT REQUEST PREVIOUS CASE MANAGER LEAVING POSITION OTHER:       |

|NEW CASE MANAGER NAME |NEW CASE MANAGER |NEW CASE MANAGER INDIVIDUAL NPI |EFFECTIVE DATE OF CHANGE |

| |TPI | | |

|      |      |      |      |

|REMAINING AUTHORIZED SERVICES (RAS) TO BE AUTHORIZED TO NEW CASE MANAGER TPI: |

|# RAS COMPREHENSIVE VISITS |# RAS FACE-TO-FACE FOLLOW-UP VISITS |# RAS TELEPHONE FOLLOW-UP VISITS |

|      |      |      |

|THE CLIENT IS A: |

|CHILD (AGE 0 -20) WITH A HEALTH CONDITION OR HEALTH RISK |

|WOMAN (OF ANY AGE) WITH A HIGH-RISK PREGNANCY |

|I attest that the client/parent/guardian has confirmed the documented needs, was informed of choice of case management providers and desires case management |

|services. |

|I confirm that the information is true and correct to the best of my knowledge |

|understand that Prior Authorization is a condition of reimbursement for services and not a guarantee of payment. |

|       |

|CASE MANAGER SIGNATURE |DATE |

|      |      |      |

|CASE MANAGEMENT AGENCY |GROUP TPI NUMBER |GROUP NPI NUMBER |

|(     )     -      |(     )     -      |      |

|PROVIDER PHONE NUMBER |PROVIDER FAX NUMBER |E-MAIL |

NOTE: ORIGINAL PAN WILL BE ADJUSTED TO THE NUMBER OF VISITS ALREADY COMPLETED. THE ORIGINAL PAN WILL END THE DAY BEFORE THE EFFECTIVE DATE OF THE NEW PAN.

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