Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE: 1.877.647.4848
FAX: 1.866.694.3649
Improving Lives
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___________________________________________________________
Check agency or provider to indicate how to authorize.
Agency/Group Name_____________________________________________
DOB_____________________________________________________________________
Provider Name____________________________________________________
Social Security #__________________________________________________________
Professional Credentials______________________________________________
Member ID #_____________________________________________________________
Last Auth #_______________________________________________________________
Address/City/State __________________________________________________
____________________________________________________________________
Phone____________________________Fax_______________________________
NPI (required)_____________________Tax ID (required)___________________
CURRENT ICD DIAGNOSIS Primary (Required)___________________________________________________
Secondary__________________________________________________________
Tertiary______________________________________________________________
Additional___________________________________________________________
Additional___________________________________________________________
WHY DID THE MEMBER ORIGINALLY PRESENT FOR TREATMENT?
CURRENT RISK/LETHALITY
Suicidal
None
Ideation
Plan*
Means*
Intent*
Past attempt date (s): _______________________________________________
Homicidal
None
Ideation
Plan*
Means*
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. )?
______________________________________________________________________________________________________________________________________________
MILD MODERATE
SEVERE
______________________________________________________________________________________________________________________________________________
MILD MODERATE
SEVERE
______________________________________________________________________________________________________________________________________________
MILD MODERATE
SEVERE
______________________________________________________________________________________________________________________________________________
CURRENT PSYCHOTROPIC MEDICATIONS
MH/SUD TREATMENT HISTORY
Prescriber:
What has member received in the past?
None
OP MH
OP SUD
IP MH
IP SUD/DETOX
Other______ List approx. dates of each service, including hospitalizations
_____________________________________________________________________
_____________________________________________________________________
Have any questions?
Call us at 1.877.647.4848
Psychiatrist
General Practitioner
Other ____________________________________________________________
Medication Name
Date Started
Compliant (Y/N)
____________________________________________________________________
____________________________________________________________________
Amount and Frequency: ____________________________________________
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_____________________________________________Member Name
Has a psychiatric evaluation been completed?
Yes___________(date)
SUBSTANCE USE DISORDER
None
By History
DRUG
No / If no, indicate why this has not been completed.
Current/Active Use
AMOUNT
Is member attending AA/NA meetings?
FREQUENCY
Yes
No
FIRST USE (DATE)
LAST USE (DATE)
If yes, how often? ________________________________________________________________
Current step ________________________________________________ Was a sponsor identified?
RELAPSE HISTORY
Yes
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?
None
Are the member’s family/supports involved in treatment?
Minimal
Yes
No
Moderate
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?
Yes
No
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?
Yes ______________(date)
No/ If no, why? ____________________________________________________________________
TREATMENT GOALS
Describe measurable goals and treatment plan agreed upon by member.
MEASURABLE GOAL
Have any questions?
Call us at 1.877.647.4848
DATE INITIATED
CURRENT PROGRESS (Please note specific progress made.)
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_____________________________________________Member Name
TREATMENT CHANGES
DISCHARGE CRITERIA
How has the treatment plan changed since the last request? ________
Objectively describe how it will be known that the member is ready ___________________________________________________________________
to discontinue treatment. _________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
REQUESTED AUTHORIZATION
Please check only one box.
Date of admission to IOP/Day Treatment _________________________________________________________________
REV 905 ( Mental Health IOP)
Total of IOP/Day Treatment sessions completed to date __________________________________________________
REV 906 ( CD IOP)
Requested start date for auth ___________________________________________________________________________
REV 907 ( Day Treatment)
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 Name
Clinician Signature
Date
SUBMIT TO:
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
PHONE 1.877.647.4848 | FAX 1.866.694.3649
1099 n. meridian street, suite 400 • indianapolis, in 46204 • 1-877-647-4848 • mhsindiana.com
members with speech or hearing disabilities call 1-800-743-3333 for tty/tdd.
MHS is a health insurance provider that has been proudly serving Indiana residents for nearly two decades through Hoosier
Healthwise, the Healthy Indiana Plan and Hoosier Care Connect. MHS also offers a qualified health plan through the Health Insurance
Marketplace called Ambetter from MHS. MHS is your choice for affordable health insurance. Learn more at mhsindiana.com.