REQUEST FOR CONCURRENT SERVICE REVIEW (RCR) SUBMIT TO MENTAL HEALTH PLAN TO: Authorization Services Alameda County Behavioral Health Care Services 2000 Embarcadero Cove, Suite 400 Oakland, CA 94606 Phone (510) 567-8141	Fax (510) 567-8148 Client Name:

Client DOB:

Client CIN or SSN:

Provider Name:

Agency, if applicable:

Provider Phone:
Please complete the above information on both pages

CLIENT PLAN UPDATE

Complete in collaboration with client whenever possible.

General Instructions: Respond legibly to all questions; indicate “N/A” or “none” if question is not relevant. Incomplete or illegible forms will be returned to sender. Clinician & client signatures are required. Please type entries to reduce returns; Submit extra page, if needed, and check this box .

Progress toward mental health objectives since last authorization (If little or no progress, indicate why):

Indicate the current specific problems in daily functioning & clinical risks that mental health services will address:

Next 6-month specific mental health objectives (observable or measurable) to support improved functioning:

Changes in treatment, medication and/or diagnosis since last authorization:

If applicable, please respond to questions from last Authorization Reviewer here:

6. Service Request for Authorization Please use one line for each service. (Not Required for HPAC)

CPT Service Code (per your rate sheet)	Service Description (per your rate sheet)	Frequency of Service	Diagnosis Code(s) Addressed
Example: x9502	Individual Therapy	1x/week	296.22

Client Name:

Client DOB:

Client CIN or SSN:

Provider Name:

Agency, if applicable:

Provider Phone:

7. Change in Special Needs?

8. Updated Strengths and Resources

Provider/Clinician information is required on the line below. _______________________________________________________________________________________________ Clinician’s printed name	Signature with discipline (e.g., MFT, LCSW, MD)	Date If Clinician is not licensed, Licensed Supervisor’s information is required on the line below: _________________________________________________________________________________________ Lic. Supervisor’s printed name	Signature with discipline (e.g., MFT, LCSW, MD)	Date *CLIENT‘S SIGNATURE:__________________________________________________________ Date______________ Legal Representative’s signature., if required:________________________________________ Date______________	Specify Legal Rep.’s Relationship (e.g., parent, guardian, conservator): __________________________________ If client/legal rep. verbally agreed with Client Plan but declined to sign, provide the Date: _________________ If client/legal rep. disagrees with Plan, provide Reason/Date: _____________________________________________________ *Client’s signature required above AND client must be offered copy of Client Plan page unless clinician believes client’s condition would suffer. If so, provide Reason/Date:_______________________________________________________________ 9. If closing case, date of last session: Referrals made: