Before a TRICARE East beneficiary under 21 is admitted to a psychiatric residential treatment center, the referring provider asks Humana Military for authorization with this six-page form. It documents the primary mental health diagnosis, symptoms in the last six months, mental status, 24 months of treatment history, barriers to community care and guardianship, with recent psychiatric and psychological evaluations attached.
The referring mental health provider completes and signs the form with their credentials, including the proposed facility (or to be determined), the ordering provider, and military hospital or clinic referral details when applicable.
Download the current version from the source each time; forms change without notice.
Residential Treatment Center (RTC) form initial review
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The referring provider, who signs it with credentials and must submit it both through Humana Military provider self-service and to the proposed RTC facility. The form also captures the ordering provider and, for military patients, the military hospital or clinic referral ID.
Records from no more than the last three to six months: a psychiatric or clinical evaluation covering presenting problem, diagnosis, treatment needs and prognosis, and a current psychological evaluation including testing. The form itself summarizes 24 months of past treatment and the barriers to community care.
No. Humana Military directs SUD residential treatment requests to the inpatient authorization form and warns that using the RTC form for SUD can delay processing or cause a denial. The RTC form is for primary mental health diagnoses in beneficiaries under 21.