Service Request Form. Intensive Outpatient Program (IOP): Continuing Review Request
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1 Please fax your completed form and treatment plan to Optum Idaho at Service Request Form Intensive Outpatient Program (IOP): Continuing Review Request Section 1: Date 1. Date of Submission (DD/MM/YYYY): Section 2: Member Information 1. Member Name: 2. Member Date of Birth (DD/MM/YYYY): 3. Member ID Number: 4. Date of Admission to Intensive Outpatient (IOP): 5. Agency Phone Number: 6. Type of IOP Requested: Mental Health (MH) IOP S9480 Substance Related IOP H Start Date: Expected End Date: Section 3: Provider Information 1. Requesting Provider Name and Credentials: 2. Agency Name and Address: 3. NPI Number: 5. Phone Number: 4. Tax Identification Number: 6. Fax Number: Section 4: Current Treatment 1. Current treatment goals (include treatment plan): 2. Progress on goals established during IOP treatment so far: 1/6
2 3. Behavior progress (groups/school/employment/family therapy/peers/adls): 4. Member strengths: 5. Has the member been significantly engaged in treatment thus far? Y N 6. Member commitment to treatment: 7. Youth member family commitment to treatment: Section 5: Risks/Ongoing Problem Potentials 1. Mental Status Exam: 2. Suicide risk assessment (ideation, recent plan, and detailed history of attempts): 3. Other known risks: 4. Eating disorder symptoms/behaviors: 2/6
3 5. IOP facility contact with outpatient providers: (List the outpatient providers you have contacted, the date contacted, and the coordination completed with them on behalf of the member.) Section 6: Medical History 1. Current medical issues/conditions: 2. Name of PCP: Phone Number of PCP: 3. Name of other involved medical providers: 4. Current medications: (including dosages and frequency of medical and psychiatric medications; please highlight changes in medication since admission) A. Current medications with dosage and frequency: 3/6
4 B. Current PRN medication dosage and frequency: C. Non psychiatric medications dosage and frequency: 5. Criteria for Discharge: (Can the behaviors/symptoms presenting for the member be managed at a lower level of care? Please explain issues and barriers.) 6. Discharge plan (include outpatient services, medical, academic/employment/natural resources and supports): 4/6
5 Adult MH IOP If continuing MH IOP for an Adult, please score the symptom measure on a 6 point scale* with: 0 = none or not at all 1 = slight or rare (less than a day or two) 2 = mild or several 3 = moderate or more than half the days 4 = severe or nearly every day 5 = all the time *Cross cutting Symptom Measure described in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and 1. Depression Anger Mania Anxiety Somatic symptoms Suicidal ideation Psychosis Sleep problems Memory Repetitive thoughts and behaviors Dissociation Personality functioning Substance use Child or Adolescent MH IOP If continuing MH IOP for a child or adolescent, please score the symptom measure on a 6 point scale* with: 0 = none or not at all 1 = slight or rare (less than a day or two) 2 = mild or several 3 = moderate or more than half the days 4 = severe or nearly every day 5 = all the time *Cross cutting Symptom Measure described in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and 1. Somatic symptoms Sleep problems Inattention Depression Anger Irritability Mania Anxiety Psychosis Repetitive thoughts Substance use Suicidal ideation /6
6 For Substance Related IOP Please update the ASAM Dimensional Rating Scale based on the member s current status: D1. Acute intoxication/and/or withdrawal potential Low Medium High D2. Biomedical conditions/complications Low Medium High D3. Emotional, behavioral, or cognitive conditions/complications Low Medium High D4. Readiness to change Low Medium High D5. Relapse/ use/ problem potential Low Medium High D6. Recovery environment Low Medium High 1. What problem(s) with High and Medium severity ratings are the greatest concerns at this time? 2. Provide specific strategies/interventions that will be utilized to address these concerns on the treatment planning section of this form: 3. Please specify any additional treatment issues or concerns that are being addressed: Name of licensed clinician completing form: Title: Signature: Contact number: optumidaho.com, Optum, Inc. All rights reserved. 6/6
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