Valueoptions Behavioral Health Provider/primary Care Physician Form printable pdf download

Member Name

Date of Birth __________

ValueOptions Behavioral Health Provider/Primary Care Physician

Communication Form

Health Plan: ______________

Member Consent to Exchange Information (to be completed by member)

I, ___________________________________, authorize/do not authorize __________________________________________,

(Please Print)

(Circle one)

(Provider's Name)

My behavioral health provider, and ______________________________, ___________________________________________

(Primary Care Physician Name)

(PCP Address and Phone Number)

to exchange information regarding my mental health /substance abuse treatment and medical healthcare for coordination of care

purposes as may be necessary for the administration and provision of my healthcare coverage. The information exchanged may

include information on mental health care or substance abuse care and/or treatment such as diagnosis and treatment plan. I

understand that this authorization shall remain in effect for one year from the date of my signature below or for the course of this

treatment, whichever is longer. I understand that I may revoke this authorization at any time by written notice to the above

behavioral healthcare provider. I also understand that it is my responsibility to notify my behavioral healthcare provider if I

choose to change my Primary Care Physician.

I Authorize Communication between My PCP

Date

and Behavioral Health Provider (Member's Signature)

I Do Not Authorize Communication between My PCP

Date

and Behavioral Health Provider (Member's Signature)

Signature of parent or guardian (if member is a minor)

Date

Witness

Date

Provider Information (to be completed by ValueOptions provider) - Please Print

____________________________________________________________________________________________

Practitioner Name(s)

Facility Name

Address

City/State

Telephone Number

(Therapist and Psychiatrist if applicable)

DSM IV Diagnosis code & name________________________________________________________________________________________

Treatment Plan: Type___________________Frequency________________Est length of Tx_________________________________________

(I.e. ind, family, group, meds)

(i.e. weekly, etc)

Medication(s) Prescribed:______________________________________________________________________________________________

____________________________________________________________________________________________________________________

Comments:___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

_____________________________________________________________________________________________

For urgent or emergency situation, please call the primary care physician in addition to sending form

Conclusion of mental health/substance treatment

Date of last session _______________ Treatment completed? Yes___

No___

Notification of prescription or change in medications (see comments)

Other:____________________________________________________________________________________

____________________________________________________________________________________________________________________

Print Clinician Name

Signature/Credentials

Telephone Number

A COPY OF THIS FORM MUST BE SENT TO THE PRIMARY CARE PHYSICIAN, RETAINING THE ORIGINAL

IN THE MEMBER'S CHART. IF THE FORM IS SENT BY FAX, ATTACH CONFIRMATION THAT FAX WAS

Please Check Method

SENT.

____________

__________________

DATE SENT

SENT BY (CLINICIAN PLEASE INITIAL)

Fax

Mail

ValueOptions PCP doc9/17/ 01

Please File in Member's Chart

Revised 2/20/03

Valueoptions Behavioral Health Provider/primary Care Physician Form

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