Bcn Behavioral Health Ip/php/iop Concurrent Review Form
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1
2Fax completed form to:
BCN Behavioral Health
1-877-706-1993
IP/PHP/IOP Concurrent Review Form
by 3 p.m. on the date of review
Phone: 1-800-482-5982
Member number:
Member name:
Review date:
Facility name:
Reviewer’s name:
MH
SA
Reviewer’s phone number:
A
Services and communication with primary care practitioner
Level of care:
IP
PHP
IOP
Date of admission:
For PHP and IOP, number of days member attended since last review:
Attending psychiatrist / Last name:
First name:
Primary care practitioner / Last name:
First name:
Offered / signed
Date:
PCP release of information:
Offered / declined
Date:
Date(s) PCP communication occurred:
B
Member’s legal status
Legal status:
Voluntary
Involuntary
If involuntary:
Deferred
Court / date: ____________
Does member have:
Guardian
Durable power of attorney
N/A
Contact information for guardian / DPOA (if applicable):
C
Justification for continued stay
Acute suicidal ideation with plan / intent (in past 24 hours):
N/A or details:
Acute homicidal ideation with plan / intent (in past 24 hours):
N/A or details:
Acute psychosis (in past 24 hours):
N/A or description:
Acute detox symptoms (in past 24 hours):
N/A or description:
Current DSM-5 diagnosis:
(Record diagnosis code(s) and description(s); related medical concerns; other psychosocial /
contextual factors.)
Signs / symptoms of acute risk factors:
Additional psychosocial / treatment history:
1
Revised November 2015
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