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Online Pre-Authorization Form

Referring Agency

Date of Referral

Contact Phone

Contact Email

How did you Hear About Us

Name Fields

First Name

Last Name

Phone Number

Date of Birth

Marital Status

Address Fields

Street Address

City

State / Province

Zip / Postal Code

Country

Gender identity:

Male Female Gender Fluid Transgender Male Transgender Female Genderqueer

Insurance

Medical Assistance (Medicaid) number

Medicaid ID

Criteria for PRP Uninsured/ State Funded Coverage Questions

Recently Incarcerated?:

Yes No

Hospitalized for mental health within the last 6 months?:

Yes No

Placed in a state hospital?:

Yes No

A RRP (Residential Rehabilitation Service) Bed within the last 6 months?:

Yes No

Reason for Referral / Presenting Problems (please be specific)

Type of Care (PLEASE CHECK ALL THAT APPLY, if qualified):

Psychiatry Medication Management Therapy Residential PRP Services (If qualifying diagnosis) Substance Abuse RecoveryTreatment ACT (Mobile Treatment)

Highest Level Of Education

Any arrest in the past 30 days?:

Yes No

Currently Employed?:

Yes No

Veteran?:

Yes No

In Iraq or Afghanistan?

Yes No

Is the client eligible for MTA pass?:

Yes No

Any Restrictions from Referring agency? If yes please Explain

Is the client on Parole or Probation if so provide parole/probation officer's name and best contact number .

Dedicated to Transforming Lives

We promote premium, holistic wellness through absolute integrity and deep compassion. Our professional team provides the supportive spaces, flexible services, and expert guidance you need to navigate life's challenges and discover lasting peace.

info@miyahomesllc.org

+1 (571) 282-5430

1804 Ocean shore ln, Salisbury MD

Our Services

Substance Use Disorder (SUD) Treatment Programs

(RES) Residential Support Program

Outpatient Mental Health Clinic (OMHC)

Health Home Program (HH)

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Contact
Book an Appointment