Service Authorization Tracking

Track service authorization requests, approvals, and denials

Needs Attention
Draft
Child Information
Basic information for service authorization tracking
Child Name:

Marcus Thompson

Date of Birth:

8/22/2015

Child ID:

CH-2024-002

Case Number:

CS-2024-0287

Service Authorizations & Denials
Track service authorization requests, approvals, and denials
1 Approved
1 Pending
2 Denied

Total Denied Cost

$450.00

Director Approved

$450.00

Running Total

$1250.00

Service Authorizations

Service TypeFrequencyProviderStatusAuth DateActions
Individual Therapy2x/weekHealing Hearts Counseling
Approved
1/15/2024
Family Therapy1x/weekFamily Solutions Center
Pending
Psychiatric Services1x/monthChildren's Mental Health Clinic
Denied
1/10/2024
TransportationAs neededSafe Rides Transport
Denied
1/8/2024
Actions
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© 2025 Refuge House Form Directory. Service Authorization Tracking Section - Draft Version