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INTENSIVE OUTPATIENT/DAY TREATMENT FORM MENTAL HEALTH/CHEMICAL DEPENDENCY-

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  • 51 check-boxes
  • 94 other fields

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CURRENT PSYCHOTROPIC MEDICATIONS
Prescriber: o Psychiatrist o General Practitioner
o Other ______________________________________________________
Medication Name Date Started Compliant (Y/N)
_____________________________________________________________
_____________________________________________________________
Amount and Frequency: _________________________________________
MH/SA TREATMENT HISTORY
What has member received in the past?
o None o OP MH o OP SA o IP MH o IP SA/DETOX
Other _________ List approx. dates of each service, including hospitalizations
______________________________________________________________
______________________________________________________________
WHY DID THE MEMBER ORIGINALLY PRESENT FOR TREATMENT?
INTENSIVE OUTPATIENT/DAY TREATMENT FORM MENTAL HEALTH/CHEMICAL DEPENDENCY-
Please print clearly – incomplete or illegible forms will delay processing.
Please mail or fax completed form to the above address.
MEMBER INFORMATION
Member Name _________________________________________________
Health Plan ___________________________________________________
DOB _________________________________________________________
SS # _________________________________________________________
Member ID # __________________________________________________
Last Auth # ____________________________________________________
CURRENT ICD DIAGNOSIS
Primary (Required)
_____________________________________________
Secondary
____________________________________________________
Tertiary
_______________________________________________________
Additional
_____________________________________________________
Additional
_____________________________________________________
CURRENT RISK/LETHALITY
Suicidal
o None o Ideation o Plan* o Means* o Intent*
Past attempt date (s): ___________________________________________
Homicidal
o None o Ideation o Plan* o Means* o Intent*
Past attempt date (s): ___________________________________________
*Please indicate current safety plans _______________________________
_____________________________________________________________
Current assaultive/violent behavior, including frequency ________________
_____________________________________________________________
Describe any risk for higher level of care, out-of-home placement, change of
placement or inability to attend work/school __________________________
_____________________________________________________________
PROVIDER INFORMATION
Check agency or provider to indicate how to authorize.
o Agency/Group Name __________________________________________
o Provider Name _______________________________________________
Professional Credentials _________________________________________
Address/City/State _____________________________________________
_____________________________________________________________
Phone ________________________ Fax ___________________________
NPI (required) __________________ Tax ID (required) ________________
CURRENT PRESENTATION/SYMPTOMS
Describe the CURRENT situation and symptoms. Impact on current functioning (occupational, academic, social, etc. )?
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
o MILD o MODERATE o SEVERE
o MILD o MODERATE o SEVERE
o MILD o MODERATE o SEVERE
Ambetter.CoordinatedCareHealth.com
SUBMIT TO:
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE 1.855.923.4633
FAX 1.866.279.1358
SUBSTANCE USE DISORDER
TREATMENT DETAILS
TREATMENT GOALS
Is member attending AA/NA meetings? o Yes o No If yes, how often? ________________________________________________________________
Current step ___________________________________________________________________ Was a sponsor identied? o Yes o No
RELAPSE HISTORY
Date of last relapse ________________________________________________________________________________________________________________
Drug and amount used _____________________________________________________________________________________________________________
Resulting consequences ____________________________________________________________________________________________________________
What therapeutic approach (e.g. evidence-based practice, therapeutic model, etc.) is being utilized with this member?
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Member’s current level of motivation? o None o Minimal o Moderate o High
Are the member’s family/supports involved in treatment? o Yes o No If no, why? ________________________________________________________
Date of last family therapy session and progress made? ____________________________________________________________________________________
What other services are being provided to this member that are not requested in this OTR? Please include frequency __________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Is care being coordinated with member’s other service providers? o Yes o No o N/A
Has information been shared with PCP regarding behavioral health provider contact information, presenting problem, date of initial visit, diagnoses and any meds
prescribed? o Yes ______________(date) o No/ If no, why? ____________________________________________________________________________
__________________________________________Member Name
Has a psychiatric evaluation been completed? o Yes___________(date) o No / If no, indicate why this has not been completed.
o None o By History o Current/Active Use
DRUG AMOUNT FREQUENCY
FIRST USE (DATE) LAST USE (DATE)
Describe measurable goals and treatment plan agreed upon by member.
MEASURABLE GOAL DATE INITIATED CURRENT PROGRESS (Please note specic progress made.)
Ambetter.CoordinatedCareHealth.com
__________________________________________Member Name
DISCHARGE CRITERIA
Objectively describe how it will be known that the member is ready to discon-
tinue treatment.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
TREATMENT CHANGES
How has the treatment plan changed since the last request?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
REQUESTED AUTHORIZATION
Date of admission to IOP/Day Treatment ____________________________________________________________
Total of IOP/Day Treatment sessions completed to date ________________________________________________
Requested start date for auth _____________________________________________________________________
Number of days per week attending ________________________________________________________________
Number of hours per day attending ________________________________________________________________
Expected discharge date ________________________________________________________________________
Additional Information?
Clinician Signature Date
Please feel free to attach additional documentation to support your request (e.g. updated treatment plan, progress notes, etc.).
Clinician Signature Date
Please check only one box.
o REV 905 (Behavioral Health IOP)
o REV 906 (SUD IOP) AR
SUBMIT TO:
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE 1.855.923.4633
FAX 1.866.279.1358
Ambetter.CoordinatedCareHealth.com
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INTENSIVE OUTPATIENTDAY TREATMENT FORM MENTAL HEALTHCHEMICAL DEPENDENCY-

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Completed 20 April 2021

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