Triwest Sar Form PDF Details

Navigating the healthcare system can be complex, especially for those who have served in the military. The TriWest Healthcare Alliance Veterans Affairs (VA) Patient-Centered Community Care (PC3) Program aims to streamline this process through the use of the Secondary Authorization Request (SAR) form. This crucial document is a bridge for veterans seeking specialized healthcare services outside the VA system. By filling out the SAR form, veterans provide detailed information about themselves, including their DoD ID/Benefits number or Sponsor SSN, contact information, service branch, and whether they have any other insurance. Additionally, the form requires details about the healthcare provider, the veteran's diagnosis, any co-occurring medical conditions relevant to the treatment, and any psychiatric hospitalizations within the last 90 days. An updated treatment plan outlining problems, goals, and treatment methods is also requested. The form culminates in a section where the healthcare provider specifies the requested authorization for treatment, including type, frequency, and duration of the proposed sessions. Designed to expedite the approval process, this form ensures veterans receive the timely and effective care they need, illustrating the program’s commitment to supporting veterans’ health and well-being. Providers are instructed to fax the completed form or upload it via the Provider Portal, emphasizing the importance of protected information for treatment, payment, or healthcare operations under HIPAA and the Privacy Act of 1974.

QuestionAnswer
Form NameTriwest Sar Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespc3 request online, sar va form, sar form va, sars form va

Form Preview Example

TriWest Healthcare Alliance

Veterans Affairs (VA) Patient-Centered Community Care (PC3) Program

PC3 - Secondary Authorization Request

Veteran’s Name:

 

 

 

 

DoD ID/Benefits # or Sponsor SSN

:

 

Date Completed:

 

 

 

 

VA Auth Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

. Vet eran’s Address:

 

 

 

 

 

 

 

2. Pat ient DOB:

 

 

Age:

2

. Cit y :

 

 

 

 

 

 

 

 

St at e:

 

Zip:

 

 

 

3

. Telephone:

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

4

. Vet eran’s Serv ic e Branc h:

Army Nav y

USAF USMC

USCG

Ot her

 

 

 

5

. Ot her I nsuranc e:

y es

 

no

 

I f y es, please spec if y :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

. Prov ider

Name:

 

 

 

 

 

 

 

Lic ense Ty pe:

 

 

 

 

 

7

. Prov ider

Telephone:

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

8

. Prov ider

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cit y :

 

 

 

 

 

 

 

 

St at e:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

.

Prov ider

TI N:

 

 

 

 

Prov ider

NPI :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. DSM-V Diagnosis

 

 

 

 

 

11. Co-Occurring Medical Conditions

 

 

 

 

 

 

 

 

 

 

 

(Relevant to Treatment)

 

 

 

 

1.

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

12. Has t he pat ient had a psy c hiat ric hospit alizat ion in t he last

90 day s:

 

y es

no

13. TREATMENT PROGRESS: (Progress toward treatment goals since last report)

Ve rs io n 1

1

TriWest Healthcare Alliance

Veterans Affairs (VA) Patient-Centered Community Care (PC3) Program

 

 

Secondary Authorization Request

 

 

 

 

 

 

 

 

 

 

 

 

Veteran’s Name:

 

 

 

DoD ID/Benefits # or Sponsor SSN

:

 

 

Date Completed:

 

 

 

VA Auth Number:

 

 

 

 

 

 

 

 

 

 

 

 

14. TREATMENT PLAN UPDATE (Please provide a brief and succinct narrative to update your treatment plan)

 

Pr o b le m s:

1 .

 

 

 

 

 

 

 

 

 

 

2 .

 

 

 

 

 

 

 

 

 

 

3 .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Goals:

1.

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methods:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Authorization Request:

 

 

 

 

 

 

 

 

 

 

 

 

Begin D ate

Fr equency

 

 

 

C PT C ode

Tr eatm ent

 

for this Auth

( 1x w eek , 1x m onth)

# of Sessions

 

End D ate

90832

I ndiv idual Psychother apy ( 30 m in)

 

 

 

 

 

 

 

 

 

90834

I ndiv idual Psychother apy ( 45 m in)

 

 

 

 

 

 

 

 

 

90837

I ndiv idual Psychother apy ( 60 m in)

 

 

 

 

 

 

 

 

 

90847

Fam ily Psy chother apy

 

 

 

 

 

 

 

 

 

90853

Gr oup Medical Psychother apy

 

 

 

 

 

 

 

 

180 day s

E/ M C ode

Phar m acologic Management

 

 

 

 

 

 

 

 

 

+ 90833

Psy chother apy w ith E/ M ( 30 m in)

 

 

 

 

 

 

 

 

 

+ 90836

Psy chother apy w ith E/ M ( 45 m in)

 

 

 

 

 

 

 

 

 

+ 90838

Psy chother apy w ith E/ M ( 60 m in)

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

Pro vid e r Sig n a t u re: _ _ _ _ _ _ _ __ __ _ __ _ __ __ _ __ _ __ _ __ __ _ __ _ __ Cre de nt ials: _ _ _ _ _ _ __ _ __ __ Da t e : _ _ _ _ _ __ __ __

Please fax the completed form to: 1-866-284-3736 or Upload via the Provider Portal

NOTE: HI PAA a u t horizat ion re qu irem en t s d o no t app ly t o pro t ect ed in form at ion u sed f or t re atm en t , p ay m ent , o r h ealt h ca re o perat ions

in clu d in g m edical re cord s re quest ed f o r t h e pro v is ion of h ealt h care serv ices . Priv acy Act St a t emen t - Th is inf orm at io n is p rot ect ed u nder t h e Priv a cy Act o f 1 9 74 an d s hall b e h andled a s “ f or o ff icial u se o nly .” Violat ions o f t h is m ay b e p unish able by f ines , im pris onm ent , or b ot h .

Ve rs io n 1

2

How to Edit Triwest Sar Form Online for Free

Working with PDF files online is always easy using our PDF editor. You can fill out triwest secondary authorization request form here effortlessly. We are aimed at providing you the best possible experience with our tool by constantly introducing new capabilities and enhancements. With these updates, working with our editor gets easier than ever before! Getting underway is effortless! What you need to do is adhere to these simple steps below:

Step 1: Click on the "Get Form" button above. It is going to open our tool so that you could begin filling in your form.

Step 2: With this online PDF tool, it is possible to do more than merely fill in forms. Try all the functions and make your forms look perfect with customized textual content put in, or optimize the original input to perfection - all that supported by the capability to insert your own graphics and sign the document off.

This form will need you to enter specific information; in order to guarantee accuracy, you should adhere to the guidelines directly below:

1. When filling in the triwest secondary authorization request form, make sure to incorporate all of the essential blank fields within the associated form section. It will help speed up the process, which allows your information to be handled fast and appropriately.

va sar form 2020 completion process detailed (portion 1)

2. Right after completing this part, go on to the subsequent stage and fill in the necessary particulars in these blanks - Has t he pat ient had a psy c, and y es.

Completing part 2 of va sar form 2020

3. The following part will be focused on Veterans Name Date Completed, DoD IDBenefits or Sponsor SSN VA, TREATMENT PLAN UPDATE Please, Goals, and Methods - complete every one of these fields.

Step # 3 for completing va sar form 2020

It is easy to make a mistake when filling out your Goals, for that reason make sure to reread it before you'll finalize the form.

4. The subsequent paragraph requires your attention in the following places: Treatment, Authorization Request, C PT C ode Tr eatm ent, I ndiv idual Psychother apy m in, E M C ode Phar m acologic, Psy chother apy w ith E M m in, Begin D ate for this Auth, Fr equency, x w eek x m onth, of Sessions, End D ate, day s, Pro vid e r Sig n a t u re, Please fax the completed form to, and Note HI PAA a u t horizat ion re. Just remember to give all requested information to go further.

Completing segment 4 of va sar form 2020

Step 3: Confirm that the details are accurate and then click "Done" to finish the project. Sign up with FormsPal now and immediately obtain triwest secondary authorization request form, ready for download. Each and every modification you make is handily kept , letting you customize the pdf further as required. When using FormsPal, you can easily complete documents without being concerned about information incidents or records getting shared. Our secure software helps to ensure that your private information is maintained safely.