Bcn Behavioral Health Ip/php/iop Concurrent Review Form Page 2
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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:
D
Treatment
Medications / Names and dosages of ALL (psychiatric and nonpsychiatric) medications:
Describe member’s response to milieu treatment:
Additional information:
E
Discharge
Anticipated d/c date:
Additional days requested:
Discharge plan:
Barriers to discharge: Check any issue listed below that is a barrier.
Housing
Poor supports
Transportation issues
Noncompliance w/ tx
Job jeopardy
Safety plan
Lack of family involvement
Other:
Provider type
Provider name
Telephone no.
Date
Time
Follow-up
Therapist/program:
appointments:
Psychiatrist:
Note: The first follow-up appointment must be scheduled for within seven days of discharge.
If the appointment is scheduled for more than seven days after discharge, explain why:
2
Revised November 2015
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