Uniform Treatment Plan Form Page 2
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3Complete the following if the request is for ECT or rTMS: Provide clinical rationale including medical suitability and history of failed treatments:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Requested Revenue/HCPC/CPT Code(s) _____________________________________ Number of Units for each __________________________
Complete the following for Applied Behavior Analysis (ABA) Requests( if the carrier classifies ABA as a mental health benefit):
Supervising BCBA Name__________________________ Has Autism Spectrum Disorder been validated by MD/DO or Psychologist?
No
For initial requests, what are specific ABA treatment goals for the patient?
1.
_______________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________________________
Date of Evaluation by MD/DO: __________________________
For continuing requests, assessment of functioning (observed via FBA, ABLLS, VB-MAPP, etc.) related to ASD including progress over the last
year:
_______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
For continuing requests what are the treatment goals and targeted behaviors, indicating new or continued, with documentation of progress and child’s
response to treatment:
1.__________________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________________
Requested Revenue/HCPC/CPT Code(s) _____________________________________ Number of Units for each __________________________
Complete the following if the request is for Psychological Testing:
Symptoms/Impairment related to need for testing:
Acute change in functioning from the individual’s previous level
Personality problems
Peculiar behaviors and/or thought process
School problems
Symptoms of psychosis
Family issues
Attention problems
Cognitive impairment
Development delay
Mood Related Issues
Learning difficulties
Neurological difficulties
Emotional problems
Physical/medical signs
Relationship issues
Other:________________________________________________________
Purpose of Psychological Testing:
Differential diagnostic clarification
Help formulate/reformulate effective treatment plan.
Therapeutic response is significantly different from that expected based on the treatment plan.
Evaluation of functional ability to participate in health care treatment.
Other: (describe) ____________________________________________________________________________________________________________
Substance use in last 30 days:
Yes
No Diagnostic Assessment Completed:
Yes Date _______/_______/________
No
Patient substance free for last ten days
Yes
No
Has the patient had known prior testing of this type within the past 12 months?
Yes
No
If so, why necessary now?
Unexpected change in symptoms
Evaluate response to treatment
Assess functioning
Other
Names and Number of Hours of each requested test_____________________________________________________________________________________________
If appropriate, complete this section: Reason(s) why assessment will require more time relative to test standardization samples?
Depressed
Vegetative
Processing speed
Performance Anxiety
Expressive/ Receptive
mood
Symptom
Communication Difficulties
Low frustration
Suspected or
Physical Symptoms or Conditions such
Other:____________________________________________
tolerance
Confirmed grapho-
as:__________________________________
___________________________________________________
motor deficits
_____________________________________
___________________________________________________
Requested Revenue/HCPC/CPT Code(s) _____________________________________ Number of Units for each __________________________
Complete the following if the request is for Biofeedback:
Requested Revenue/HCPC/CPT Code(s) _____________________________________ Number of Units for each __________________________
Complete the following if the request is for Telehealth:
Requested Revenue/HCPC/CPT Code(s) _____________________________________ Number of Units for each __________________________
Patient Membership Number_________________
UTP Page 2
Complete for Higher Level of Care Requests (e.g. inpatient, residential, intensive outpatient and partial hospitalization):
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