Fillable Behavioral Health (BH) Concurrent Review Form (Absolute Total Care)

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Behavioral Health (BH) Concurrent Review Form (Absolute Total Care)

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The Behavioral Health (BH) Concurrent Review Form (Absolute Total Care) form is 1 page long and contains:

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®
SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
Behavioral Health (BH) Concurrent Review Form
Reviewed Clinical History (Previous Authorizations, Impact Pro, etc.): Yes No
BILLING PROVIDER
Facility: UR/Phone #: LOC:
Fax: NPI #:
Voluntary or Involuntary: Admit Date:
DIAGNOSTIC AND TREATMENT INFORMATION
Dx:
Current Medica
tions/Changes (Dates):
PRN’s (Da
te, Time):
Compliance:
BAL/UDS:
Health Updat
es:
Precaution
s:
Tx Plan Progr
ess:
Physician Not
es: (Include Date/MSE):
Staff Notes:
Therapy Notes:
 
Barriers to Discharge:
Discharge Criteria/Plan:
Discharge Planner:
Phone #:
ELOS:
Things to Address Next Review:
absolutetotalcare.com
ATC-02132020-P-2
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Behavioral Health (BH) Concurrent Review Form (Absolute Total Care)

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Completed 5 May 2021

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