Outpatient Registration Form (Orf 1)

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OUTPATIENT REGISTRATION FORM (ORF 1)
Current Risk Assessment:
Requested Start Date for this Authorization ____/____/____
Scale:: 0 = none
1 = mild, ideation only
NOTE: This form cannot be used to request ECT or psychological testing.
2 = moderate, ideation with EITHER plan or history of attempts
3 = severe, ideation AND plan, with either intent or means
Type of Service Requested:
Mental Health
Substance Abuse
na = not assessed
(Please select/circle one value for each type of risk)
Patient Name: ________________________________________________________
Date of Birth: ____________________________ Age: _____________
M
F
Patient’s risk to self:
0
1
2
3
na
Address (City/State only): ______________________________Tel #: ___________
Patient’s risk to others:
0
1
2
3
na
Patient’s Insurance ID#: ________________________________________________
Patient’s Employer/Benefit Plan: _________________________________________
Current Impairments: (Please select/circle one value for each type of impairment)
Scale: 0=none 1=mild/mildly incapacitating
2=moderate/moderately incapacitating
Provider Name: _____________________________________License: _________
3=severe or severely incapacitating
na=not assessed
Provider Program/Clinic (if applicable): ___________________________________
VO Provider # (if known): ______________________________________________
Mood Disturbance (Depression or Mania)
0
1
2
3
na
Service Address: _____________________________________ Tel #: ___________
Anxiety
0
1
2
3
na
City/State/Zip: ________________________________________________________
Psychosis/Hallucinations/Delusions
0
1
2
3
na
Are you independently licensed to provide services in the State where you are treating
Thinking/Cognition/Memory/Concentration Problems
0
1
2
3
na
this patient?
Yes
No
Impulsive/Reckless/Aggressive Behavior
0
1
2
3
na
ID #: __________________________ Check Which:
SSN
Tax ID
NPI
Activities of Daily Living Problems
0
1
2
3
na
Weight Change Associated with a Behavioral Diagnosis
0
1
2
3
na
• Is patient currently receiving disability benefits?
Y
N
Unknown
Medical/Physical Condition
0
1
2
3
na
The patient’s chart reflects that:
• I am treating this patient according to VO treatment guidelines.
Y
N
NA
Substance Abuse/Dependence
0
1
2
3
na
• I am coordinating this patient’s case with other behavioral/medical providers as
Job/School Performance Problems
0
1
2
3
na
appropriate.
Y
N
NA
• The treatment plan was developed with the patient and has measurable, time-
Social/Relationship/Marital/Family Problems
0
1
2
3
na
limited goals.
Y
N
NA
Legal Problems
0
1
2
3
na
REQUESTED SERVICES: Please indicate type(s) of service provided and frequency.
DSM-IV Diagnosis:
Medication Management 90862
Wkly
Mnthly
Qtrly
Other ______
Please indicate primary diagnosis:
Indiv. Psychotherapy (20-30 min) 90804
Wkly
Mnthly
Qtrly
Other ______
Axis I __________________________ Axis II: ____________________________
Indiv. Psychotherapy (45-50 min) 90806
Wkly
Mnthly
Qtrly
Other ______
Indiv. Psychotherapy w/Med Mgmnt 90807
Wkly
Mnthly
Qtrly
Other ______
Medical Conditions (Axis III): Please check patient’s medical conditions
Family Psychotherapy (45-50 min) 90847
Wkly
Mnthly
Qtrly
Other ______
None
Asthma/COPD
Cancer
Cardiovascular Problems
Group Therapy (60-90 min) 90853
Wkly
Mnthly
Qtrly
Other ______
Chronic Pain
Dementia
Diabetes
Obesity
Other _____________________________
Wkly
Mnthly
Qtrly
Other ______
Other: _____________________________________________
Other _____________________________
Wkly
Mnthly
Qtrly
Other ______
Treating Provider’s Signature: ____________________________________________
Date: ______________________
ValueOptions 2005 Rev. 1.03.08

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