Fillable ASAM LEVEL 3.7WM ASAM level 3.7 withdrawal management (Triadex Services)

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ASAM LEVEL 3.7WM ASAM level 3.7 withdrawal management (Triadex Services)

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Country of origin: US
File type: PDF

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coaccess.com | 800-511-5010 |
PERSON COMPLETING AND SUBMITTING THIS FORM:
Name: Facility:
Phone number: Fax: Date form submied:
ADMITTING FACILITY (IF KNOWN):
Facility name:
NPI: Ancipated/Actual admit date:
MEMBER INFORMATION:
Member name:
DOB: State ID:
Select the line of business or organizaon this request is for:
☐ Child Health Plan Plus oered by Colorado Access (CHP+ HMO) ☐ Regional Accountable Enty (RAE) Region 3
☐ Child Health Plan Plus State Managed Care Network (CHP+SMCN) ☐ Regional Accountable Enty (RAE) Region 5
☐ Regional Accountable Enty - Denver Health MCO (RAE DH MCO)
Primary diagnosis (ICD-10): Secondary diagnosis (ICD-10):
Connued on the next page
SERVICE PRIORITY:
☐ Prospecve (paent not yet admied for services).
☐ Concurrent (paent has already started services and needs addional services).
ASAM LEVEL 3.7WM
ASAM level 3.7 withdrawal management services only
Please complete the following secon and aach any relevant clinical informaon to support this request.
Withdrawal substance(s): for each substance requiring withdrawal management, please list any use informaon/history
that is relevant to the withdrawal risk:
Substance 
☐ Alcohol Current blood alcohol level
(BAL):
☐ Heroin Posive toxicology screen?
☐ Yes
☐ No
☐ Other opiates Posive toxicology screen?
☐ Yes
☐ No
☐ Benzodiazepines Posive toxicology screen?
☐ Yes
☐ No
coaccess.com | 800-511-5010 |

☐
Headache ☐ Body aches ☐ Tremors ☐ Cravings
☐ Abdominal pain ☐ Stomach cramps ☐ Fever ☐ Diabetes
☐ Seizures or ☐ History of seizures ☐ Nausea/vomiting ☐ Sweats/chills ☐ Insomnia
☐ Delirium tremens or ☐ History of delirium tremens ☐ Diarrhea ☐ Hypertension ☐ Asthma
☐ Other (please specify):___________________________________________________________________________
Current vitals:
Blood pressure: Oxygen:
Pulse: Respiraon:

☐
Suicidal ideation
☐ Homicidal ideation
☐ Psychosis/paranoia/grave disability
If yes, please give explanation:

Any withdrawal medicaons already iniated:
Any other medicaons:
01 06-154 0321A

at 
ASAM LEVEL 3.7WM
☐ Other (please specify) Posive toxicology screen?
☐ Yes
☐ No
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ASAM LEVEL 3.7WM ASAM level 3.7 withdrawal management (Triadex Services)

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Completed 17 June 2021

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