®
SUBMIT TO
Utilization Management Department
PHONE 1-866-433-6041 FAX 1-866-694-3649
OUTPATIENT TREATMENT REQUEST FORM
Please print clearly. Please feel free to attach additional documentation to support your request (e.g., updated treatment plan, progress notes, etc.).
MEMBER INFORMATION
Date
Name
Date of Birth
Member ID #
PROVIDER INFORMATION
Provider Name
Provider/Agency Tax ID #
Provider/Agency NPI Sub Provider #
Phone Fax
CURRENT ICD DIAGNOSIS
Primary
Secondary
Tertiary
Additional
Additional
Has contact occurred with PCP? YES NO
Date First Seen By Provider/Agency
Date Last Seen By Provider/Agency
FUNCTIONAL OUTCOMES (TO BE COMPLETED BY PROVIDER DURING A FACE-TO-FACE INTERVIEW WITH MEMBER OR GUARDIAN. QUESTIONS
ARE IN REFERENCE TO THE PATIENT.)
1. In the last 30 days, have you/your child had problems with sleeping or feeling sad? Yes (5) No (0)
2. In the last 30 days, have you/your child had problems with fears and anxiety? Yes (5) No (0)
3. Do you/your child currently take mental health medicines as prescribed by your doctor? Yes (0) No (5)
4. In the last 30 days, has alcohol or drug use caused problems for you or your child? Yes (5) No (0)
5. In the last 30 days, have you/your child gotten in trouble with the law? Yes (5) No (0)
6. In the last 30 days, have you/your child actively participated in enjoyable activities with family or friends (e.g., recreation, hobbies, leisure)? Yes (0) No (5)
7. In the last 30 days, have you/your child had trouble getting along with other people including family and people outside the home? Yes (5) No (0)
8. Do you/your child feel optimistic about the future? Yes (0) No (5)
Children Only:
9. In the last 30 days, has your child had trouble following rules at home or school? Yes (5) No (0)
10. In the last 30 days, has your child been placed in state custody (DCF criminal justice)? Yes (5) No (0)
Adults Only:
11. Are you currently employed or attending school? Yes (0) No (5)
12. In the last 30 days, have you been at risk of losing your living situation? Yes (5) No (0)
THERAPEUTIC APPROACH/EVIDENCE BASED TREATMENT USED
LEVEL OF IMPROVEMENT TO DATE
Minor Moderate Major No Progress to Date Maintenance Treatment of Chronic Condition
BARRIERS TO DISCHARGE
SYMPTOMS (IF PRESENT, CHECK DEGREE TO WHICH IT IMPACTS DAILY FUNCTIONING.)
N/A Mild Moderate Severe
Anxiety/Panic Attacks
Decreased Energy
Delusions
Depressed Mood
Hallucinations
Angry Outbursts
N/A Mild Moderate Severe
Hyperactivity/Inattention
Irritability/Mood Instability
Impulsivity
Hopelessness
Other Psychotic Symptoms
O t h e r (inclu d e s e v e r i t y ) : _______________________________________________________________
ABSOLUTETOTALCARE.COM
ATC-07022020-P-1
