Uniform Treatment Plan Form

ADVERTISEMENT

Uniform Treatment Plan Form
Carrier or Appropriate Recipient:
(For Purposes of Treatment Authorization)
Today’s Date ______________
PATIENT INFORMATION
PRACTITIONER INFORMATION
PATIENT’S FIRST NAME
PATIENT’S DATE OF BIRTH
PRACTITIONER ID# or TAX ID
PHONE NUMBER
/
/
PRACTITIONER/FACILITY NAME, ADDRESS, FAX AND PHONE
MEMBERSHIP NUMBER
AUTHORIZATION NUMBER (If Applicable)
_______________________________________________________________
Date[[/Time]] Patient First Seen For
This Episode Of Treatment __/__/____[[@____:_____am/pm]]
Level of care being requested: Please specify benefit type:
Mental Health
Substance Use Disorder
Outpatient
Intensive Outpatient Program
Partial Hospitalization Program
Acute IP
IP Rehab
Acute IP Detox
Residential
ECT
rTMS
Applied Behavior Analysis (ABA)
Psychological
Testing
BioFeedback
Telehealth
Other ____________________________
Primary Dx Code: ________________________
Secondary Dx Code(s): ______________________________
Current Treatment Modalities: (check all that apply)
Psychotherapy:
Behavioral
CBT
DBT
Exposure
Supportive Therapy
Problem Focused
Interpersonal
Psychodynamic
EMDR
Group
Couples
Family
Other________________________________________________________
Medical Evaluation and Management
Type of Medications(if not applicable, no response is required):
Antipsychotic
Anxiolytic
Antidepressant
Stimulant
Injectables
Hypnotic
Non-psychotropic
Mood Stabilizer
Other ____________________________________________
Current Symptoms and Functional Impairments: Rate the patient’s current status on these symptoms/functional impairments, if applicable.
Current Ideation Current Plan
Prior Attempt
None
Suicidal
Homicidal
Symptoms/ Functional Impairments
None
Mild
Moderate
Severe
Self-Injurious Behavior
Substance Use Problems
Depression
Agitated/aggressive Behavior
Mood Instability
Psychosis
Anxiety
Cognitive Impairment
Eating Disorder Symptoms
Social/ Familial/School/WorkProblems
ADL Problems
If requesting additional outpatient care for a patient, why does the patient require further outpatient care:
Maintenance treatment for a
chronic condition
Consolidate treatment gains
Continued impairment in functioning
Significant regression
New symptoms and/or
impairments
Supportive treatment due to other treatment plan changes
complex psychiatric and medical co-morbidity
Complex
Psychiatric and Substance abuse Co-morbidity
other________________________________________________________________________________________________________________
Signature of Practitioner: _____________________________________
Date: ______/______/_______
My signature attests that I have a current valid license in the state to provide the requested services.
Patient Membership Number_________________
UTP Page 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 3