Get Outpatient Form 2015-2024

OUTPATIENT TREATMENT REPORT INSTRUCTIONS Please print all information. Fax completed form to 866-834-7469 NH. PATIENT Name ID PROVIDER Individual and/or Group Tax ID Address City DOB License State ICD-10 DIAGNOSIS ES numeric description Phone ZIP Fax MEDICAL CONDITIONS None Chronic pain Asthma/COPD Dementia Cancer Diabetes Cardiovascular problems Obesity Other CURRENT RISK ASSESSMENT Suicidal Ideation Homicidal MEDICATIONS Medication Plan Intent Psychotropic Medical Hx of harming self Hx of harming others N/A Prescribing MD PCP Psychiatrist If affective or psychotic disorder is present and no medications are prescribed please explain COORDINATION OF CARE TREATMENT HISTORY I have communicated with patient s Inpatient Within past yr 1 to 3 yrs ago More than 3 yrs ago Specialist Therapist Outpatient SYMPTOMS and FUNCTIONAL IMPAIRMENT If present check degree On disability Yes No Mild Mod. Severe Anxiety Hopelessness Obsessions/Compulsions Decreased energy ADLs Significant weight change Delusions Family/Relationships Panic attacks Depressed mood Inattention Sleep disturbance Hallucinations Irritability/Mood instability Physical health Hyperactivity Impulsivity Work/School Substance abuse/Dependence Active In remission If substance abuse is current or focus of treatment complete the information below Substance of choice Amount Frequency Date of last use Alcohol Is patient currently participating in a community-based support group Marijuana Includes AA NA etc* Heroin Opioids Cocaine list If Yes frequency of attendance Prescrip* drugs Is there a sponsor Inhalants DESIRED OBSERVABLE OUTCOMES Patient agrees with treatment goals PROVIDER S CONTINUED TREATMENT PLAN Modality and CPT Code Individual 90832 x per wk Couple/Family 90847 Group 90853 Other mo yr Anticipated Completion mo s TREATMENT PROGRESS Level of improvement to date No progress to date of sessions provided to date Start date for new authorization My signature confirms that I am providing the requested services. Minor Moderate Major Maintenance tx of chronic condition Provider s signature FAX to 866-834-7469 NH Anthem UM Services PO BOX 892 North Haven CT 06473 Date 1-800-228-5975 Rev 08102015. PATIENT Name ID PROVIDER Individual and/or Group Tax ID Address City DOB License State ICD-10 DIAGNOSIS ES numeric description Phone ZIP Fax MEDICAL CONDITIONS None Chronic pain Asthma/COPD Dementia Cancer Diabetes Cardiovascular problems Obesity Other CURRENT RISK ASSESSMENT Suicidal Ideation Homicidal MEDICATIONS Medication Plan Intent Psychotropic Medical Hx of harming self Hx of harming others N/A Prescribing MD PCP Psychiatrist If affective or psychotic disorder is present and no medications are prescribed please explain COORDINATION OF CARE TREATMENT HISTORY I have communicated with patient s Inpatient Within past yr 1 to 3 yrs ago More than 3 yrs ago Specialist Therapist Outpatient SYMPTOMS and FUNCTIONAL IMPAIRMENT If present check degree On disability Yes No Mild Mod. Severe Anxiety Hopelessness Obsessions/Compulsions Decreased energy ADLs Significant weight change Delusions Family/Relationships Panic attacks Depressed mood Inattention Sleep disturbance Hallucinations Irritability/Mood instability Physical health Hyperactivity Impulsivity Work/School Substance abuse/Dependence Active In remission If substance abuse is current or focus of treatment complete the information below Substance of choice Amount Frequency Date of last use Alcohol Is patient currently participating in a community-based support group Marijuana Includes AA NA etc* Heroin Opioids Cocaine list If Yes frequency of attendance Prescrip* drugs Is there a sponsor Inhalants DESIRED OBSERVABLE OUTCOMES Patient agrees with treatment goals PROVIDER S CONTINUED TREATMENT PLAN Modality and CPT Code Individual 90832 x per wk Couple/Family 90847 Group 90853 Other mo yr Anticipated Completion mo s TREATMENT PROGRESS Level of improvement to date No progress to date of sessions provided to date Start date for new authorization My signature confirms that I am providing the requested services.