CurrentCareSourcePolicy N/A

Antipsychotic Medication Informed Consent for Behavioral/Psychiatric Clients

Template and required documentation for informed consent when initiating or changing antipsychotic medication or delivery system for behavioral/psychiatric members managed by CareSource PASSE. Affects prescribers, members (and parents/guardians), and CareSource pharmacy case management.

Policy Summary

PayerCareSource

PolicyAntipsychotic Medication Informed Consent for Behavioral/Psychiatric Clients

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a newly signed and dated informed consent form to CareSource PASSE Pharmacy Fax: 1-866-930-0019.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsrecommended interval for labs

originalprescriber signature type

1-866-930-0019CareSource PASSE Pharmacy Fax

Coverage Criteria

Required consent and documentation for antipsychotic changes

Covered when ALL of the following are met

Policy Summary

PayerCareSource

PolicyAntipsychotic Medication Informed Consent for Behavioral/Psychiatric Clients

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a newly signed and dated informed consent form to CareSource PASSE Pharmacy Fax: 1-866-930-0019.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Informed consent and documentation: A newly signed and dated informed consent form by all parties is required for changes in antipsychotic chemical entity or delivery system; completed form must include member, prescriber, medication recommendation, prescriber section, and signatures.

Form must be faxed to CareSource PASSE Pharmacy as indicated.

No explicit clinical exclusions are listed on the informed consent form. The document focuses on documenting shared decision-making, counseling topics, and medication risks rather than enumerating conditions or diagnoses that would be excluded from the consent process.

The form requires submission of specific supporting documentation; therefore, failure to provide required items (progress/chart notes, psychiatric evaluation, after‑care plan if inpatient, labs every 6 months, psycho‑social history, and the completed informed consent form) may prevent authorization or coverage of the medication change.

Coding and Monitoring

Example diagnosis codes provided on formmixed

F31.81	example ICD-10 code shown on form
296.89	example DSM-5 code shown on form

Labs monitoring interval

Recommended monitoring intervalLabs every 6 months

Required lab documentationLabs documented and submitted as part of supporting materials

Relation to authorizationFailure to submit labs every 6 months may contribute to non-authorization or denial

Provider Actions & Submission Requirements

Prior Authorization

Informed consent and submission

A newly signed and dated informed consent is required. Fax the completed form to CareSource PASSE Pharmacy at 1-866-930-0019. For questions, contact the PASSE Pharmacy.

Documentation Required

Prior medication history collection

The informed consent form collects the member's prior medication history and current/started medications. Providers must complete the medicines previously used field and the other medicines continued or started field to document prior medication history for operational and clinical review.

Documentation Required

Required supporting documentation

Prescribers must submit all required supporting documentation with the informed consent form. Failure to submit the required documents may result in non-coverage or denial of the medication request.

Progress/chart notes
Psychiatric evaluation
After-care plan (for inpatient discharges)
Laboratory monitoring as indicated — at minimum labs every 6 months
Psycho-social history and supports
Completed, newly signed and dated informed consent form

Documentation Required

Form fields and signatures

The informed consent and medication recommendation form must include completed member, prescriber, and witness fields; a medication recommendation section (drug name, strength, quantity, form, dosing instructions); diagnosis and coding (ICD-10 and DSM-5 where applicable); targeted symptoms the medication is intended to address; and evaluation fields indicating timing of comprehensive mental health/developmental/behavioral evaluations and counseling/behavioral interventions. Prescriber original signature (not copied, stamped, or e-signature) and parent/guardian signature (when applicable) with dates and printed names are required.

Prescriber information: last name, first name, NPI, DEA, phone, fax
Medication recommendation: drug name, strength, quantity, form, dosing instructions
Medication history fields: medicines previously used; other medicines continued or started
Diagnosis: clinical diagnosis, ICD-10 code, DSM-5 code
Targeted symptoms and evaluation timing (more than 12 months, within the past 12 months, current referral, no evaluation planned)
Counseling/behavioral intervention status (past, current, referred provider, no) and comments
Signatures: prescriber original signature and date, prescriber printed name; parent/guardian signature and date, relationship, printed name; witness signature and printed name

Denial Risk

Missing required documentation

Missing any of the required documentation listed (progress notes, psychiatric evaluation, after-care plan when applicable, labs at least every 6 months, psycho-social history, or the completed informed consent form) may lead to denial or non-coverage of the medication.

Antipsychotic Medication Informed Consent

Antipsychotic medication informed consent

Education topics: Parent/guardian must be informed about expectations without treatment, with counseling only, with medicine only, with both, possible side effects (including potential permanence), FDA approval status for pediatric use, how to stop medication, missed dose instructions, and need for regular doctor visits.

Consent statement documents understanding and right to refuse medication at any time.

Definitions

Comprehensive evaluation — documented timeframes

DefinitionA comprehensive mental health or developmental/behavioral evaluation documented on the form as having been performed within specified timeframes

Documented timeframes (options on form)More than 12 months; the past 12 months; Current referral; No evaluation planned

Location on formPrescriber section includes checkboxes for evaluation timing and space for comments

Background

This document is an informed consent template for antipsychotic medications used with behavioral and psychiatric clients. It documents diagnosis and targeted symptoms, records counseling about risks and alternatives, and captures parental/guardian acknowledgment of key topics including the role of counseling with or without medication, the right to refuse treatment, potential side effects (including possible permanence), FDA approval status for pediatric use, instructions for stopping or missed doses, and the need for regular follow‑up. The prescriber must also supply supporting clinical materials—progress notes, psychiatric evaluation, after‑care plan when applicable, labs every 6 months, and psycho‑social history—when submitting the completed consent for processing.