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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Please fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255 TREATMENT CONTINUATION REQUEST FORM Behavioral Health Unit * All Sections must be completed for timely approval Patient Name: Member I.D. #: Date of Birth: Provider Name: Phone Number: Address: NPI #: Date of Evaluation Visit for current Episode of Care: Assessment: Clinical Disorders/Syndromes Is this request urgent? No Diagnosis Code: Diagnosis Code: Personality Disorders/Intellectual Disabilities Relevant Medical Issues/Physical Problems Does the patient have a current medical condition linked to the Axis 1 or 2 diagnosis? Please describe below: Describe: Psychosocial Stressors Please indicate the severity of current Psych Social Stressors: GAF GAF Score: Highest Past Year: Current: Current Medications: Anti-Pyschotic Hypnotic Psycho-Stimulant Yes Anti-Anxiety Mood Stabilizer Other/Comments: Risk Assessment: Suicidal Ideation Homicidal Ideation Symptoms: (if present, check degree) Mild Moderate Depressed Mood Anhedonia Low Energy Hopelessness Somatoform/ Factitious Problems Social Isolation Self Mutilation Sleep Disturbance Mood Swings Obsessions/Compulsions Ideation Severe None Mild Yes Moderate Anti-Depressant Medical Plan Anxiety Panic Attacks Inattention Impulsive Bingeing/Purging Restricting Food Intake Hyperactive Hallucination Delusions Other Psychotic Symptoms No Symptoms Severe None Intent Mild No Moderate None Severe Substance Abuse/Addictions: Active Drug Use Cravings Drug Seeking Behavior Guilt/Remorse/Shame Preoccupation with getting high Preoccupation with Gambling Is this patient on mental health or chemical dependency disability? Have you contacted the patient's PCP? Have you contacted any other health care provider? If yes, list who. Other Provider: Abuse in Remission None Yes Yes Yes No No No Interventions & Goals Used in Treatment: 1. Time Frame to Complete: 1 month 2 months 3 months Other 1 month 2 months 3 months Other 1 month 2 months 3 months Other 2. Time Frame to Complete: 3. Time Frame to Complete: Frequency of Appointments Schedule: Weekly 2 x a month Monthly Other: Specific Services Requested and Number of Services Requested: CODE Number of Services (1-12) 90846 90791 90833 90847 90792 90836 90853 90838 90832 90834 90785 90837 Other: E&M Code: Number of Services: Level of Improvement to Date: None Minor Moderate Major Additional Symptoms, Functioning Level and Comments: Date Provider Signature ** Please Note ** Only evaluation sessions and crisis encounters will be reimbursed prior to authorization requests. Print Form