Fillable Substance Use Disorder (SUD) Initial Review Form (Adult) (Absolute Total Care)

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Substance Use Disorder (SUD) Initial Review Form (Adult) (Absolute Total Care)

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The Substance Use Disorder (SUD) Initial Review Form (Adult) (Absolute Total Care) form is 2 pages long and contains:

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SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
Substance Use Disorder (SUD) Initial Review Form (Adult)
Reviewed Clinical History (Previous Authorization, Impact Pro, etc.): Yes
No
BILLING PROVIDER
Facility: UR
/Phone #:
AS
AMLOC:
F
ax #:
NPI #: A
dmit Date:
T
ax ID #:
V
oluntary or Involuntary:
Guar
dian:
Phone #:
DIAGNOSTIC AND TREATMENT INFORMATION
Dx:
A
ttending MD:
Phone #:
Precipitating Event:
SUD HX/USE: Substance Age First Use Amount Frequency Last Use
Tx Hx:
UDS
UDS
/BAL:
CO
WS/CIWA score (If Available):
A
t Admission:
Cur
rent:
De
tox:
Withdr
awl Sx:
Vitals (F
or IP Detox):
MEDICAL HISTORY
Medical Hx:
Cur
rent Medicine Changes:
OP Meds:
ATC-02132020-P-4
absolutetotalcare.com
PSYCHOLOGICAL HISTORY
Psych Hx:
SI/HI/AVH:
Abuse/Trauma Hx:
Family Hx:
STATE OF CHANGE
TRIGGERS
Triggers for Use:
Longest Sobriety:
SUPPORT SYSTEM
Sober Suport System:
Lives With:
Legal:
Education: Employment:
Discharge Criteria: Plan:
Discharge Barriers:
Discharge Planner: Phone #:
ELOS:
Planned Therapeutic Leave Days Within Authorization Period (Where/Why):
If Request Is Sent To Peer Review (P2P) Please Indicate:
Name (DR/UR): Phone #:
Date/Time Within Next 24 Hours for P2P:
absolutetotalcare.com
SUBMIT TO:
Utilization Management Department
PHONE 18665345976 FAX 18665356974
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Substance Use Disorder (SUD) Initial Review Form (Adult) (Absolute Total Care)

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Completed 5 May 2021

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