Carelon Behavioral Health: Attestation to Discharge Conflicting/Overlapping Authorization(s) Due to Non-Overlap Requirement

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Full Name *

Maryland Medicaid Participant ID *

Date of Birth *

YYYY

Purpose

Certain services are not permitted to overlap according to COMAR 10.09.80.06B. You can also refer to the Combination of Mental Health Services document or the Combination of SUD Services document on Carelon’s website for additional details. This attestation documents the participant’s (or Authorized Representative’s) request to receive services with the provider listed above and to discharge/end any conflicting, overlapping authorization(s) that prevent authorization and/or delivery of those services. If the participant has any questions, they can call customer service at 1-800 -888-1965 to ask for additional details.

By signing below, I attest and agree that:

1. I am (check one): *

The participant identified above, OR

The participant’s Authorized Representative/ legal guardian with legal authority to act on the participant’s behalf.

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