Initial Registration Form

This is the Maine Behavioral Health ASO KEPRO CareConnection® Authorization Request Form. This form is to be used by providers to submit request for Initial Registration for MaineCare members and other consumers as appropriate.

Fields with a (*) next to them are required. Please submit this information via KEPRO CareConnection® whenever possible. If necessary, you may complete and fax this form to KEPRO at 1-866-325-4752. Please call KEPRO Provider Relations with any questions, as 1-866-527-0027, Option 1.

*Member Information

*Member MaineCare ID:

*Member First Name: *Member Last Name:

*Member SSN:	*Date of Birth:

*Gender: Female Male Unknown	Phone Number (with area code):

*Address of Record:

*City:	*State:	*Zip Code:

*AMHI Consent Decree Class Member: YES NO

*Race:	White	Black or African American	Alaskan Native

Native Hawaiian	American Indian	Hispanic

Asian	Other Pacific Islander	Other Race

Unknown

Guardian/Power of Attorney

Guardian Organization (if applicable): Child Welfare Elder Services Office of Cognitive Disabilities

Guardian First & Last Name: Phone Number:

Guardian Address:

City: State: Zip Code:

Relationship to Member:	Family Member Friend Agency Spouse Other

Additional Information:

*Administrative Data

*Authorization Type:

*Organization:

* Submission Date: *Requested Start Date of Service:

* Review Type:

*Category of Service: CHOOSE ALL THAT APPLY

Adult Mental Health	Children’s Services

Community Integration	Targeted Case Management

Intensive Case Management	Inpatient Services

Assertive Community Treatment	Day Treatment

Daily Living Support Services	Crisis Support Services

Skills Development	Infant Mental Health

Day Supports	Children’s Outpatient

Specialized Group Services	Family PsychoEducational

Crisis Supports Services	Child Assertive Community Treatment

Hospital Services – Acute	Medication Services

Home Based	Child & Family Behavioral Health Treatment

Group Psychotherapy	Community Based Treatment without Permanency

Medication Management	Private Non-Medical Crisis Unit

Psychotherapy	Treatment Foster Care

PNMI	Children’s PNMI Services

Psychological Services	Multidimensional Treatment Foster Care

Family PsychoEducational	Baxter Fund Services

Community Rehabilitation Services	Provided by an Educational System

Long-Term Supported Employment	Rehab and Community Support Services – Section 28

Baxter Fund Services	Partial Hospitalization

Dorothea Dix/Riverview	Intensive Outpatient Program

Partial Hospitalization	Behavioral Health Homes

Intensive Outpatient Program

Home and Community Benefits for Adults	Substance Abuse Services

Behavioral Health Homes	Inpatient Substance Abuse

Outpatient Substance Abuse

Grant-Funded Adult Services	Intensive Outpatient Program

Community Integration

Assertive Community Treatment	Psychological Services

Daily Living Support Services	Psychological Services

Community Rehabilitation Services

Location (for PNMI, Crisis Units, & Hospitals):

Referral date:	Location at Time of Referral: Hospital Community

Date Case Worker Assigned: Date Seen Face to Face:

*Requesting Agency/Facility

* Requesting Facility/Agency Name:

* Requesting Staff First & Last Name:

*Requesting Staff Phone (with Area Code):

UM/Supervisor Name/Phone:

*Procedure Request

*Procedure Request

*Service Code:

*Frequency:	*Units:

*Start Date: *NPI Number:

*Service length and end date will automatically populate based on the type of service. The units for most services will also auto-populate.

Additional Information

*Additional Information

*Provider Name:

*Provider Electronic Signature:

*Date: