Download 9.3 BH Unit - Forms - Treatment Continuation Request FormPRINT P1

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.
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