SUBMIT TO:
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE 1.855.745.5507
FAX 1.844.273.2331
INTENSIVE OUTPATIENT/DAY TREATMENT FORM MENTAL HEALTH/CHEMICAL DEPENDENCY
Please print clearly – incomplete or illegible forms will delay processing.
Please mail or fax completed form to the above address.
MEMBER INFORMATION
PROVIDER INFORMATION
Member Name__________________________________________________
Health Plan____________________________________________________
DOB__________________________________________________________
SS #__________________________________________________________
Member ID #___________________________________________________
Last Auth #_____________________________________________________
Check agency or provider to indicate how to authorize.
o Agency/Group Name___________________________________________
o Provider Name________________________________________________
Professional Credentials__________________________________________
Address/City/State ______________________________________________
_____________________________________________________________
Phone_________________________ Fax____________________________
NPI (required)___________________ Tax ID (required)_________________
CURRENT ICD DIAGNOSIS Primary (Required)______________________________________________
CURRENT RISK/LETHALITY
Secondary_____________________________________________________
Suicidal
Tertiary________________________________________________________
o None
Additional______________________________________________________
Additional______________________________________________________
WHY DID THE MEMBER ORIGINALLY PRESENT FOR TREATMENT?
o Ideation
o Plan*
o Means*
o Intent*
Past attempt date (s): ____________________________________________
Homicidal
o None
o Ideation
o Plan*
o Means*
o Intent*
Past attempt date (s):____________________________________________
*Please indicate current safety plans________________________________
_____________________________________________________________ Current assaultive/violent behavior, including frequency _________________
_____________________________________________________________
Describe any risk for higher level of care, out-of-home placement, change of
placement or inability to attend work/school___________________________
_____________________________________________________________
CURRENT PRESENTATION/SYMPTOMS
Describe the CURRENT situation and symptoms.
Impact on current functioning (occupational, academic, social, etc. )?
________________________________________________________________________________________________________________________________
o MILD o MODERATE o SEVERE
________________________________________________________________________________________________________________________________
o MILD o MODERATE o SEVERE
________________________________________________________________________________________________________________________________
o MILD o MODERATE o SEVERE
________________________________________________________________________________________________________________________________
CURRENT PSYCHOTROPIC MEDICATIONS
MH/SA TREATMENT HISTORY
Prescriber:
What has member received in the past?
o None
o OP MH
o OP SA
o IP MH
o IP SA/DETOX
o Psychiatrist
o General Practitioner
o Other _______________________________________________________
Other__________ List approx. dates of each service, including hospitalizations
Medication Name
Date Started
Compliant (Y/N)
______________________________________________________________
_____________________________________________________________
______________________________________________________________
_____________________________________________________________
Amount and Frequency: __________________________________________
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__________________________________________Member Name
Has a psychiatric evaluation been completed?
o Yes___________(date)
o No / If no, indicate why this has not been completed.
SUBSTANCE USE DISORDER
o None
o By History
DRUG
o Current/Active Use
AMOUNT
Is member attending AA/NA meetings?
FREQUENCY
o Yes
o No
FIRST USE (DATE)
LAST USE (DATE)
If yes, how often?_________________________________________________________________
Current step____________________________________________________________________ Was a sponsor identified?
RELAPSE HISTORY
o Yes
o No
Date of last relapse_________________________________________________________________________________________________________________
Drug and amount used______________________________________________________________________________________________________________
Resulting consequences_____________________________________________________________________________________________________________
TREATMENT DETAILS
What therapeutic approach (e.g. evidence-based practice, therapeutic model, etc.) is being utilized with this member?
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Member’s current level of motivation?
o None
Are the member’s family/supports involved in treatment?
o Minimal
o Yes
o No
o Moderate
o High
If no, why? ________________________________________________________
Date of last family therapy session and progress made?_____________________________________________________________________________________
What other services are being provided to this member that are not requested in this OTR? Please include frequency ___________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Is care being coordinated with member’s other service providers?
o Yes
o No
o N/A
Has information been shared with PCP regarding behavioral health provider contact information, presenting problem, date of initial visit, diagnoses and any meds
prescribed?
o Yes ______________(date)
o No/ If no, why? _____________________________________________________________________________
TREATMENT GOALS
Describe measurable goals and treatment plan agreed upon by member.
MEASURABLE GOAL
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DATE INITIATED
CURRENT PROGRESS (Please note specific progress made.)
__________________________________________Member Name
TREATMENT CHANGES
DISCHARGE CRITERIA
_____________________________________________________________
Objectively describe how it will be known that the member is ready to discontinue treatment.
_____________________________________________________________ _____________________________________________________________
_____________________________________________________________ _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
How has the treatment plan changed since the last request?
REQUESTED AUTHORIZATION
Please check only one box.
o REV 905 (Behavioral Health IOP)
o REV 906 (SUD IOP) AR
Date of admission to IOP/Day Treatment _____________________________________________________________
Total of IOP/Day Treatment sessions completed to date _________________________________________________
Requested start date for auth ______________________________________________________________________
Number of days per week attending _________________________________________________________________
Number of hours per day attending _________________________________________________________________
Expected discharge date _________________________________________________________________________
Additional Information?
Please feel free to attach additional documentation to support your request (e.g. updated treatment plan, progress notes, etc.).
Clinician Signature
Date
Clinician Signature
Date
SUBMIT TO:
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE 1.855.745.5507
FAX 1.844.273.2331
Ambetter.IlliniCare.com