What are The ASAM Criteria^®, Fourth Edition Service Request Forms?

The ASAM Criteria provides a shared language to facilitate more effective communication between providers and payers. ASAM has developed standardized forms for providers to make service authorization requests of payers for both admission and continued service. The forms are organized by ASAM Criteria Dimensions and subdimensions and provide structured information on risk ratings, Dimensional Drivers, and level of care adjustments. They also prompt providers to include information on relevant standard measures such as the COWS and CIWA scores for patients experiencing withdrawal. The continued service form also capture summaries of progress and transition plan information. These forms are free to use. 

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Service Request Form - Admission

Download Fillable Form

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Continued Service Request Form

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Additional Payer Resources

• The ASAM Criteria Navigator
• Utilization Management ASAM Criteria Training (in development)