Fillable Behavioral Health Initial Review Form (Absolute Total Care)

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Behavioral Health Initial Review Form (Absolute Total Care)

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SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
Behavioral Health Initial Review Form
Reviewed Clinical History (Previous Authorizations, Impact Pro, etc.): Yes No
BILLING PROVIDER
Facility: UR
/Phone #
L
OC:
F
ax #:
NPI #:
DIAGNOSTIC AND TREATMENT INFORMATION
Admit Dx: Admit Date:
Attending Physician: Phone #:
Other Insurance:
Guardian:
(If FC, CPS Case Worker) Name: Phone #:
Voluntary or Involuntary:
Admit Symptoms:
MSE:
Psych Hx, (Including Medications, IP Stays, and OP Providers):
Trauma/Abuse History:
Family Mental Health Hx:
Hx of Suicide Attempts (Date, Means):
Meds at Admission/Compliance:
Any Changes Since Admit:
Current Compliance:
PRN’s (Date, Time):
SI/HI (Intent/Plan):
Psychosis (Type/Intensity):
ATC-02132020-P-1
absolutetotalcare.com
PHYSICAL HEALTH INFORMATION
PhysicalHealthHx: BMI Allergies Current Diagnoses
Ht/Wt:
Substance Hx: Amount Frequency First Use Last Use Length of Use Method
COWS/CIWA Score If Available: At Admission: Current:
Vitals (For IP Detox):
UDS/BAL (Labs):
SOCIAL FACTORS
Social Factors Impacting Need for IP: Education Employment Legal
Support System: Name Relationship Participation In IP treatment
Precautions:
Admitting Treatment Plan/Any Progress:
ELOS: At Admission: Current:
D/C Criteria/Plan: 7 day F/U Dates Times Contact info
Placement Issues (FC):
absolutetotalcare.com
SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
Barriers to Successful Discharge:
Hospital DC Planner: Phone #:
Things to Address on Next Review:
LCD:
Sent Task/Referral to ICM & Set Task for CCR:
FOR PRTF LOC:
Therapeutic Leave Days (TLDs) (overnights) may be requested for this level of care to support the member’s treatment plan goals and
successful transition into the community for a maximum total of 5 per treatment episode. The member’s treatment needs and safety
remain the primary focus, therefore safety plans need to be in place.
Are you requesting any TLDs for the next review period?
How many/dates/where will they go/& goals for TLDs?
absolutetotalcare.com
SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
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Behavioral Health Initial Review Form (Absolute Total Care)

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Completed 5 May 2021

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