PO Box 80, Buffalo, New York 14240-0080
Mental Health Outpatient Treatment Review (OTR) Form Fax 1-866-390-0864 Service 1-877-837-0814
[email protected]
Member:
Member DOB:
Member ID:
Provider Name:
Provider Group/Clinic:
Service Address:
Provider ID/NPI:
Provider Telephone:
Provider Fax:
City/State/Zip:
Email:
Mental Health/Substance Abuse History
Yes
No Previous mental health treatment inpatient/outpatient? If yes, complete the following:
Level of care:
Dates Tx:
Level of care:
Dates Tx:
Level of care:
Dates Tx:
Yes No Drug/alcohol use (in past 12 months)? If YES, complete the following:
Substance
Amount
Frequency
Age Began
Last Used
Clinical Assessment
Current Signs/Symptoms
Yes
Yes
Yes
No
No
No
Generalized anxiety
Depressed Mood
Appetite Disturbance
Yes
Yes
Yes
No
No
No
Pressured Speech
Weight Loss/Gain
Panic Attacks
Yes
Yes
Yes
No
No
No
Loose Associations
Psychomotor Retardation
Concentration/Attention
Problems
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Sleep Disturbance
Low Energy
Agitation
Labile
Irritability
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Phobias
Obsessions/Compulsions
Circumstantial/Tangential
Sexual Dysfunction
Paranoid Ideation
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Impulse control problems
Conduct problems
Oppositional behaviors
Acute Stress Disorder
Other
Oriented x3
Impaired Judgment
Yes
Yes
No
No
Impaired Memory
Other Cognitive Impairment
Yes
Yes
No
No
Delusions
Hallucinations
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
HOMICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
ABUSE RISK:
Verbal
Emotional
Physical
Sexual
Mental Status
Yes
Yes
No
No
Risk Assessment
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
SUICIDAL RISK:
Ideation
Intent
Plan
Means
Attempt
Medication Name/Dosage/Frequency
Rx by: Psychiatrist
PCP
Not applicable:
1.
2.
3.
Diagnosis (please include mental health diagnosis in Axis I, if applicable)
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V: Current GAF =
REV January 2013
Page year GAF =
1
R7112A
Member:
Treatment Plan
ID#
GOAL #
Progress/Lack of progress on goal:
Goal Status:
Accomplished & removed
Continue
Additional progress needed
Revised – see new goal/objective
Continue
Additional progress needed
Revised – see new goal/objective
Continue
Additional progress needed
Revised – see new goal/objective
GOAL #
Progress/Lack of progress on Goal:
Goal status:
Accomplished & removed
GOAL #
Progress/Lack of progress on Goal:
Goal Status:
Accomplished & removed
Discharge criteria/plan:
Treatment Request
Date of first visit for this episode of care:
Requested start date for this registration:
Number of sessions to date:
Please indicate type(s) of service requested and frequency:
Diagnostic Evaluation 90791 or 90792 (medical)
Wkly
Mthly
Qrtly
Other
Family Psychotherapy (45-50 min) 90847
Wkly
Mthly
Qrtly
Other
Individual Psychotherapy (30 minutes) 90832
Group Psychotherapy (60-90 min) 90853
Wkly
Wkly
Mthly
Qrtly
Other
Mthly
Individual Psychotherapy (45 minutes) 90834
Other Code(s):
Wkly
Wkly
Mthly
Qrtly
Other
Clinician Signature:
Mthly
Qrtly
Other
Qrtly
Other
Date:
2