Outpatient Treatment Report Form Page 2
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2OUTPATIENT TREATMENT REPORT
Patient Name: ______________________________ Case Number: ______________________
NUMBER OF ADDITIONAL SESSIONS TO TERMINATION:
TREATMENT FREQUENCY:
(Please check)
____ Less than 5
____ 10-14
Date first seen: _______________ Date last seen: __________________
____ 5 – 9
____ 15 or more (explain)
Total visits seen: ______________
__________________________
Number of sessions used since last authorization: ____________________
Date you request this authorization to begin if possible: ___________________
Frequency of sessions:
Weekly
Every two weeks
Monthly
Other: ___________________________
PROPOSED TREATMENT:
NUMBER OF SESSIONS REQUESTED:
Problem #1: _____________________________________________________
90804 Psychotherapy for 20-30 minutes _______________
Measurable outcome: _______________________________________________
90806 Psychotherapy for 45-50 minutes _______________
Treatment plan: ___________________________________________________
90847 Family psychotherapy for 45-50 minutes _______________
_________________________________________________________________
_________________________________________________________________
90862 Medication management ____________
Problem #2: ______________________________________________________
90805 Therapy with medication management for 20-30 min _______
Measurable outcome: _______________________________________________
90807 Therapy with medication management for 45-50 min _______
Treatment plan: ___________________________________________________
_________________________________________________________________
90853 Group Therapy* _________ (see below)
_________________________________________________________________
Problem #3: ______________________________________________________
S9480 Intensive Outpatient Therapy: _____________
Measurable outcome: ________________________________________________
For IOP: Length of sessions: ___________________
Treatment plan: ____________________________________________________
How many sessions per week ___________
_________________________________________________________________
_________________________________________________________________
Other: ___________________
________
Estimated discharge date: _____________________
*Request for Group Therapy requires completion of Group Addendum Form.
Discharge plan: _____________________________________________
To obtain form, contact BHS Precertification at 1-800-228-0286 x7765.
____________________________________________________________
**If Group Therapy provider is a different practitioner than previously indicated:
Practitioner’s Name: ______________________________________________
Additional comments: ________________________________________
Licensure: _____________________ Phone Number: ___________________
____________________________________________________________
____________________________________________________________
OTHER TREATMENT OR SERVICES PATIENT RECEIVES:
Practitioner’s Signature:
1. _______________________________________________________________
________________________________________
Date: _____________________________
2. _______________________________________________________________
FOR MUTUAL OF OMAHA USE ONLY
Authorization with CPT codes: __________________________________________ Start date: ______________ End date: ____________
Authorized by: _________________________________________________ Date: _________________
Last revised 07/01/05
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