Member s Freedom of Choice
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- Oswin Little
- 6 years ago
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1 Member s Freedom of Choice Magellan in Louisiana Fax to Freedom of Choice Form I am aware that providers and facilities available to me can be found, within the Members tab and Provider Search, on the Magellan of Louisiana website ( The provider I choose is: (enter provider name and phone number in box) By signing below, I acknowledge that I freely choose to receive services from the above provider, and I acknowledge my responsibility to notify my previous provider in order to coordinate care. (member signature in box), Member Name: Member Date of Birth: Member/ Legal Guardian Signature: Legal Guardian Name: Today s Date: Instructions for Provider: A Freedom of Choice Form is required prior to service authorizations. The form requires a member signature, date, an identified provider and provider telephone number. This provider assumes responsibility of coordinating care with the prior provider of record. Provider Representative Signature: Revised 01/01/2013
2 ONCE COMPLETED FAX TO ( ) Page 1 of 16 Community Based Services Authorization Request (Check Services Being Requested) may be used to communicate regarding missing & incomplete information, but not for notice of authorizations. Please check your provider website for authorization information. ACT (18-20) CPST (21+) PSR (21+) Individual PSR (21+) Group ACT (21 +) CPST/PSR (under 21) Homebuilders (0-18) FFT (10-18) MST (12-17) Member Last Name: First: Date of Initial Request: Concurrent Review Funding Source: Medicaid OBH UNK SSN: Medicaid Number: Date of Birth: If Adult Medicaid, is Independent Assessment Completed and 1915i eligibility determined? Yes No (If No, authorization cannot be completed.) For ALL NEW requests, is Freedom of Choice Form Completed? Yes No (If No, authorization cannot be completed.) Legal Guardian: Phone: Cell Phone: Guardian Address: Provider: Phone: MIS #: Fax: Name & Credentials: ( may be used to communicate regarding missing & incomplete information, but not for notice of authorizations.)
3 ONCE COMPLETED FAX TO ( ) Page 2 of 16 Member Demographics: Please complete the following demographic information relating to the member Gender Pregnant Male Female YES NO Single Parent IV Drug User YES NO N/A YES NO Substance use while pregnant Does Mbr have PCP YES NO N/A YES NO Relationship Status Race Married Divorced Domestic Partner Widow(er) Never Married Unknown White/Caucasian Asian American Indian Alaskan HI/Pacific Islander Black/African-American Other Unknown Ethnicity Cent/So American Mex/Mex American Cuban Puerto Rican Non-Hisp or Non Latino Hispanic/Latino Hisp/Latin unk origin Unknown Admission Driver ER Psychiatrist Police Therapist Probation PCP Group Home ACT Team School Corrections Clinical Team Child & Family Team (CST) Medical Hospital Parent/guardian/family/friend Foster Care Program Children & Youth Svc Special Thx Fstr Care N/A Referring Agency OJJ DOE OBH DCFS N/A Child involved with agency OJJ DOE DCFS N/A Presenting Problem Alcohol/Drug Medical/Physical Family/Children Mood/Depression Other s Emot/Health Danger to Self/Others Trauma/Disaster Sevr Imprmnt/Gravely Disabled
4 ONCE COMPLETED FAX TO ( ) Page 3 of 16 Type of residence Home Homeless Board & Care Shelter Residential Hotel No Residence Single Family Dwelling Foster Home Group Home/Halfway Prvt Resd W/Fmly/Ext Fmly/NR Unknown Veteran Status YES NO UNK Clinical Information: Identified Client Abilities, Aptitudes, Skills, and Strengths Family Support Good Self Care Handicraft Skills Capacity for Insight Shows Concern for Others Enjoys Music Adequate Intelligence Ability to Stand Up for Own Rights Plays a Musical Instrument Adequate Verbal Skills Good Physical Health Ability to Express Feelings Good Self Esteem Ability to Make Decisions Positive Cultural Identity Imagination and Creativity Other: Enjoys Reading Diagnostics: Axis I: (Primary Dx) Enter specific Dx Code in blank ADHDs Schizo-DOs Disruptive Bx DO Anxiety DOs Bipolar DOs Adjustment DO Depress DOs Opp Def DO PTSD Psychotic DO Conduct DO Deferred Other (or 2 nd DX): Axis II: Borderline Personality DO Mental Retardation Antisocial Personality DO Defer Other: Axis III: Hypertension Obesity Asthma Diabetes Seizure DO Defer Other:
5 ONCE COMPLETED FAX TO ( ) Page 4 of 16 Axis IV: Problems related to - Primary Support Social Environment Educational Achievement Occupation Housing Economic/ Financial Access to Health Care Legal Other: Defer Axis V: GLOBAL ASSESSMENT OF FUNCTIONING (GAF): HIGHEST GAF PAST YEAR: CURRENT GAF: Defer Current Medications and Dose Targeted Symptoms Psychiatric Hospitalizations within past 6 months: Other MH/SA Services: Describe previous OP MH/SA services prior to this request. Was the member engaged? Were they successful? No previous Outpatient Services have been provided. Agency/Provider Dates Client Report of Successful Outcome Routine OutPt Routine OutPt Routine OutPt Routine OutPt CPST/PSR Other OJJ/ Probation/ Parole/
6 ONCE COMPLETED FAX TO ( ) Page 5 of 16 Severe Symptoms: Most recent behaviors and duration (describe) include risk of harm: Activities of Daily Living: Current Strengths: Current Weaknesses: Funcitonal Impairment: School: Home: Community: Member Goals: What are the member s goals for him/herself? What are the goals of the family?
7 ONCE COMPLETED FAX TO ( ) Page 6 of 16 Other Supports: (Family, support groups, natural supports) Collaboration: Are you working with another agency, school, or CSOC on behalf of the member? Discharge/Transition Plan: What is the timeline for the member to achieve treatment goals? What is the referral plan upon discharge? Other Notes as Appropriate:
8 ONCE COMPLETED FAX TO ( ) Page 7 of 16 Concurrent Review 1: Date of Concurrent Review: Changes to Member Demographics: Psychiatric Hospitalizations since last review: Changes to Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Current Medications and Dose: Progress toward Treatment Goals: Identified Changes to Treatment Plan: Service Authorization Criteria for Continued Treatment:
9 ONCE COMPLETED FAX TO ( ) Page 8 of 16 Units requested: ACT (18-20) for treatment dates: to ACT (21+) for treatment dates: to CPST (21+) for treatment dates: to PSR (21+)-Ind for treatment dates: to PSR (21+)-Group for treatment dates: to MST (12-17) for treatment dates: to MST Consultant approval form included (If No, authorization cannot be completed.) CPST/PSR (<21) for treatment dates: to Hbuilders (0-18) for treatment dates: to FFT (0-10) for treatment dates: to Other Notes As Appropriate:
10 ONCE COMPLETED FAX TO ( ) Page 9 of 16 Concurrent Review 2: Date of Concurrent Review: Changes to Member Demographics: Psychiatric Hospitalizations since last review: Changes to Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Current Medications and Dose: Progress toward Treatment Goals: Identified Changes to Treatment Plan: Service Authorization Criteria for Continued Treatment:
11 ONCE COMPLETED FAX TO ( ) Page 10 of 16 Units requested: ACT (18-20) for treatment dates: to ACT (21+) for treatment dates: to CPST (21+) for treatment dates: to PSR (21+)-Ind for treatment dates: to PSR (21+)-Group for treatment dates: to MST (12-17) for treatment dates: to MST Consultant approval form included (If No, authorization cannot be completed.) CPST/PSR (<21) for treatment dates: to Hbuilders (0-18) for treatment dates: to FFT (0-10) for treatment dates: to Other Notes As Appropriate:
12 ONCE COMPLETED FAX TO ( ) Page 11 of 16 Concurrent Review 3: Date of Concurrent Review: Changes to Member Demographics: Psychiatric Hospitalizations since last review: Changes to Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Current Medications and Dose: Progress toward Treatment Goals: Identified Changes to Treatment Plan: Service Authorization Criteria for Continued Treatment:
13 ONCE COMPLETED FAX TO ( ) Page 12 of 16 Units requested: ACT (18-20) for treatment dates: to ACT (21+) for treatment dates: to CPST (21+) for treatment dates: to PSR (21+)-Ind for treatment dates: to PSR (21+)-Group for treatment dates: to MST (12-17) for treatment dates: to MST Consultant approval form included (If No, authorization cannot be completed.) CPST/PSR (<21) for treatment dates: to Hbuilders (0-18) for treatment dates: to FFT (0-10) for treatment dates: to Other Notes As Appropriate:
14 ONCE COMPLETED FAX TO ( ) Page 13 of 16 Concurrent Review 4: Date of Concurrent Review: Changes to Member Demographics: Psychiatric Hospitalizations since last review: Changes to Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Current Medications and Dose: Progress toward Treatment Goals: Identified Changes to Treatment Plan: Service Authorization Criteria for Continued Treatment:
15 ONCE COMPLETED FAX TO ( ) Page 14 of 16 Units requested: ACT (18-20) for treatment dates: to ACT (21+) for treatment dates: to CPST (21+) for treatment dates: to PSR (21+)-Ind for treatment dates: to PSR (21+)-Group for treatment dates: to MST (12-17) for treatment dates: to MST Consultant approval form included (If No, authorization cannot be completed.) CPST/PSR (<21) for treatment dates: to Hbuilders (0-18) for treatment dates: to FFT (0-10) for treatment dates: to Other Notes As Appropriate:
16 ONCE COMPLETED FAX TO ( ) Page 15 of 16 Concurrent Review 5: Date of Concurrent Review: Changes to Member Demographics: Psychiatric Hospitalizations since last review: Changes to Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Current Medications and Dose: Progress toward Treatment Goals: Identified Changes to Treatment Plan: Service Authorization Criteria for Continued Treatment:
17 ONCE COMPLETED FAX TO ( ) Page 16 of 16 Units requested: ACT (18-20) for treatment dates: to ACT (21+) for treatment dates: to CPST (21+) for treatment dates: to PSR (21+)-Ind for treatment dates: to PSR (21+)-Group for treatment dates: to MST (12-17) for treatment dates: to MST Consultant approval form included (If No, authorization cannot be completed.) CPST/PSR (<21) for treatment dates: to Hbuilders (0-18) for treatment dates: to FFT (0-10) for treatment dates: to Other Notes As Appropriate:
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