Identifying Data. Provider Information. Diagnoses
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1 Outpatient Treatment Request OutpatientTreatmentRequest Faxcompletedformto: Filloutcompletelytoavoiddelays Date: / / RequestType(Checkone): Standard Expedited(additionalinformationrequiredbelow) ProviderAttestation(ExpeditedRequestsOnly) Clinicaljustificationforexpeditedreview: Bysigningbelow,Icertifythatapplyingthestandardreviewtimeframeforthisservicerequestmayseriouslyjeopardizethelifeor healthofthepatientorthepatient sabilitytoregainmaximumfunction. Physician/clinicianname: Signature: IdentifyingData First: Middle: Last: HealthPlanID: DateofBirth: / / Gender: Male Female Address: State: Zip: ProviderInformation Providername: NPI#: Phone:( ) Fax:( ) OtherCurrentBHProvider(s) Checkone: MemberagreedtoreleaseofinformationtotheirPCPand/orothertreatingprovidersdated. Memberhasbeeninformedforreleaseofinformationandhasdeclined. Diagnoses AxisI AxisV AxisII AxisIV AxisIII HighestGAFinpastyear: 73
2 PsychotropicMedications Medication Previous or current? Changed sincelast report? Dosage Frequency Adherent? ClinicalInformation Checkallthatapply Symptoms Mild Moderate Severe Acute Persistent Symptoms Mild Moderate Severe Acute Persistent AnxietyDisorders PsychoticDisorders Obsessions/compulsions Delusions/paranoia GeneralizedAnxiety Selfcaredeficits PanicAttacks Hallucinations,Type: Phobias Respondingtointernal stimuli Somaticcomplaints Disorganizedthoughtprocess PTSDsymptoms Looseassociations OTHER: OTHER: Depression SubstanceUseDisorder Impairedconcentration Lossofcontrolofdosage Impairedmemory Amnesicepisodes Psychomotorretardation Legalproblems Sexualissues Alcoholabuse Appetitedisturbance Opiateabuse Irritability Prescriptionmedicationabuse Agitation Polysubstanceabuse Sleepdisturbance OTHER: Hopelessness/Helplessness PersonalityDisorder OTHER: Oddness/eccentricities Mania/Hypomania Oppositional Insomnia Disregardforlaw Grandiosity Recurringselfinjuries PressuredSpeech Senseofentitlement Racingthoughts/flightofideas Passiveaggressive Poorjudgment/impulsivity Dependency Sexualpreoccupation Manipulation OTHER: OTHER: 74 Page2of5 BHOPTreatmentForm Lastupdated:November2013
3 CooccurringMedicalConditions Symptoms Mild Moderate Severe Acute Chronic Symptoms Mild Moderate Severe Acute Chronic Risk Factors None Ideation withplan Ideation without plan RiskFactors Checkallthatapply Intentwith means Intent without means Current? History? Suicide Homicide Abuse None Victim Patientis Perpetrator Doesabuseor neglect involveachild orelder? Abusehas beenlegally reported Current? History? Physical Sexual SocialHistory (Last3yearsifknown) Barriers/RiskFactors Currentor History? Family/Interpersonal relationships Job/School Housing FamilyHistoryof MentalIllness/ SubstanceUse Disorder CurrentSupports/ProtectiveFactors Page3of5 BHOPTreatmentForm Lastupdated:November
4 TreatmentHistory LevelofCare Inpatient psychiatric Inpatient SubstanceUse Disorder Partial Hospitalization (PHP) TreatmentGoals 1. #of distinct episodes/ sessions Dateof last treatment Alllevelsofcare LevelofCare IntensiveOutpatient (IOP) Outpatientpsych (individualorgroup) Outpatientsubstance abuse(individualor group) TreatmentGoalsandOutcomes Completefieldsbelowand/orattachcurrenttreatmentplan #of distinct episodes/ sessions Dateof last treatment Objectiveoutcomecriteriabywhichgoalwillbemeasured: ExpectedOutcomeandPrognosis(checkallthatapply) Returntonormalfunctioning Expectedimprovement,anticipatedlessthanbaselinefunctioning Relieveacutesymptoms,returntobaselinefunctioning Maintaincurrentstatus,preventdeterioration Discharge/TerminationPlan(includeestimateddischargedate) 76 Page4of5 BHOPTreatmentForm Lastupdated:November2013
5 RequestedAuthorizations Service Code #Units requested ServiceStart Date Requestedby: Phone: Fax: Faxcompletedformto: Filloutcompletelytoavoiddelays ServiceEnd Date Page5of5 BHOPTreatmentForm Lastupdated:November
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