CURRENT ICD DIAGNOSIS
OUTPATIENT TREATMENT REQUEST FORM
Please print clearly – incomplete or illegible forms will delay processing.
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 had problems with sleeping or feeling sad? Yes (5) No (0)
Yes (5) No (0)
Yes (0) No (5)
Yes (5) No (0)
Yes (5) No (0)
2. In the last 30 days, have you had problems with fears and anxiety?
3. Do you currently take mental health medicines as prescribed by your doctor?
4. In the last 30 days, has alcohol or drug use caused problems for you?
5. In the last 30 days, have you gotten in trouble with the law?
6. In the last 30 days, have you 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 had trouble getting along with other people including family and people out the home?
Yes (5) No (0)
8. Do you feel optimistic about the future?
9. Are you currently employed or attending school?
10. In the last 30 days, have you been at risk of losing your living situation?
Yes (0) No (5)
Yes (0) No (5)
Yes (5) No (0)
Therapeutic Approach/Evidence Based Treatment Used:
MEMBER INFORMATION
Name: ______________________________________________________
Date of Birth: ________________________________________________
Member ID #: ________________________________________________
PROVIDER INFORMATION
Provider Name (print): _________________________________________
Provider/Agency Tax ID #: ______________________________________
Provider/Agency NPI Sub Provider #:______________________________
Phone #: _____________________ Fax #: ________________________
Date:_____________________________
*Primary: ____________________________________________________
Secondary: ___________________________________________________
Tertiary: _____________________________________________________
Additonal : ___________________________________________________
Additonal:
Has contact occurred with PCP? Yes No
____________________________________________________
Date rst seen by provider/agency: ______________________________
Date last seen by provider/agency: ______________________________
LEVEL OF IMPROVEMENT TO DATE
Minor Moderate Major No progress to date Maintenance treatment of chronic condition
Barriers to Discharge:
SYMPTOMS
Anxiety/Panic Attacks
Decreased Energy
Delusions
Depressed Mood
Hallucinations
Angry Outbursts
Hyperactivity/Inattention
Irritability/Mood Instability
Impulsivity
Hopelessness
Other Psychotic Symptoms
Other (include severity): _______________________________________
N/A Mild Moderate Severe N/A Mild Moderate Severe
FUNCTIONAL IMPAIRMENT RELATED SYMPTOMS (IF PRESENT, CHECK DEGREE TO WHICH IT IMPACTS DAILY FUNCTIONING.)
ADLs
Relationships
Substance Abuse
Last Date of Subtance Use:______________________________
Physical Health
Work/School
Drug(s) of Choice: ____________________________________________
N/A Mild Moderate Severe N/A Mild Moderate Severe
SUBMIT TO
Utilization Management Department
Phone: 1-855-766-1497 Fax: 1-877-725-7751
ALLWELL FROM ABSOLUTE TOTAL CARE | PAGE 1
