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Carrier or Appropriate Recipient Magellan Behavioral Health Fax 800-365-5030 - or PO Box 4930 Columbia Maryland 21046-4930 State of Maryland Erase Form Uniform Treatment Plan Form For Purposes of Treatment Authorization PATIENT INFORMATION PATIENT S FIRST NAME PRACTITIONER INFORMATION PATIENT S DATE OF BIRTH / PHONE NUMBER MEMBERSHIP NUMBER AUTHORIZATION NUMBER If Applicable Date Patient First Seen For This Episode Of Treatment Have you communicated with the PCP/other relevant health care practitioners about treatment Yes No DSM-IV MULTIAXIAL DIAGNOSIS PLEASE COMPLETE ALL FIVE AXES AXIS I Dx Code. Does the patient have a current general medical condition that is potentially relevant to the understanding or management of the condition s noted in Axis I or II Severity of current psychosocial stressors None Mild AXIS V GAF Score Moderate Highest Past Year Severe At first Session Current Current Medications if not applicable no response is required Anti-psychotic Anti-anxiety Anti-depressant Psycho-stimulant Hypnotic Non-psychotropic Mood stabilizer/Anti-convulsant Other Injectables Symptoms Please rate the patient s current status on these symptoms if applicable. If not applicable no response is required* Present Absent Ideation Plan Prior Attempt Suicidal ideation Self-injurious behavior Homicidal ideation Substance use problems Authorization Request Details CPT Code Number of Units Complete this section only if a second CPT is needed* Frequency once a week etc* Requested Start Date of Authorization // Signature of practitioner My signature attests that I have a current valid license in the state to provide the requested services. Does the patient have a current general medical condition that is potentially relevant to the understanding or management of the condition s noted in Axis I or II Severity of current psychosocial stressors None Mild AXIS V GAF Score Moderate Highest Past Year Severe At first Session Current Current Medications if not applicable no response is required Anti-psychotic Anti-anxiety Anti-depressant Psycho-stimulant Hypnotic Non-psychotropic Mood stabilizer/Anti-convulsant Other Injectables Symptoms Please rate the patient s current status on these symptoms if applicable. If not applicable no response is required* Present Absent Ideation Plan Prior Attempt Suicidal ideation Self-injurious behavior Homicidal ideation Substance use problems Authorization Request Details CPT Code Number of Units Complete this section only if a second CPT is needed* Frequency once a week etc* Requested Start Date of Authorization // Signature of practitioner My signature attests that I have a current valid license in the state to provide the requested services.

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