Outpatient Review Form - Valueoptions
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1
2Outpatient Review Form
Requested Start Date for this Authorization ____/____/____
Current Impairments: (Please select/circle one value for each type of impairment)
Scale: 0=none 1=mild/mildly incapacitating 2=moderate/moderately incapacitating
.
3=severe or severely incapacitating na=not assessed
NOTE: This form cannot be used to request ECT or psychological testing
•
Mood Disturbance (Depression or Mania)
0 1 2 3 na
Type of Service Requested:
Mental Health
Substance Abuse
•
Anxiety
0 1 2 3 na
Patient Name: _______________________________________________________
•
Psychosis/Hallucinations/Delusions
0 1 2 3 na
•
Thinking/Cognition/Memory/Concentration Problems
0 1 2 3 na
Date of Birth: ___________________Age: ______________
M
F
•
Impulsive/Reckless/Aggressive Behavior
0 1 2 3 na
Address (City/State only): ______________________________________________
•
Activities of Daily Living Problems
0 1 2 3 na
Tel #: _____________________Patient’s Insurance ID#:______________________
•
Weight Change Associated with a Behavioral Diagnosis
0 1 2 3 na
Patient's Employer/Benefit Plan: _________________________________________
Select One:
Gain
Loss
na of _________ lbs. in last three months
Current weight = _____ lbs.
na Height = ________ft. ______ inches
na
•
Medical/Physical Condition
0 1 2 3 na
Provider Name: ________________________________License _______________
•
Substance Abuse/Dependence
0 1 2 3 na
Name of Program/Clinic (if applicable): ___________________________________
Select all that apply:
Alcohol
Illegal Drugs
Prescription Drugs
VO Provider ID # (if known): ________________Tel #_______________________
•
Job/School Performance Problems
0 1 2 3 na
Service Address: ______________________________________________________
•
Social/Relationship/Marital/Family Problems
0 1 2 3 na
City/State/Zip: _______________________________________________________
•
Legal Problems
0 1 2 3 na
Are you independently licensed to provide services in the State where you are treat-
Treatment Plan: Reason for continued treatment (please select primary reason)
ing this patient?
Yes
No
Remains symptomatic
Prepare for discharge within coming month
ID #: _____________________ Check Which:
SSN
Tax ID
NPI
Maintenance
Facilitate return to work
Diagnosis:
Please indicate type(s) of service provided BY YOU, and the frequency.
Axis I: 1. ________________________
2. __________________________
Medication Management 90862
Wkly
Monthly
Qtrly
Other ______
Axis II: 1. ________________________
2. __________________________
Indiv. Psychotherapy (20-30 min) 90804
Wkly
Monthly
Qtrly
Other ______
Axis III: 1. ________________________
2. __________________________
Indiv. Psychotherapy (45-50 min) 90806
Wkly
Monthly
Qtrly
Other ______
Indiv. Psychothrpy w/Med Mgmnt 90807
Wkly
Monthly
Qtrly
Other ______
Axis IV: 1. ________________________
2. __________________________
Family Psychotherapy (45-50 min) 90847
Wkly
Monthly
Qtrly
Other ______
Axis V: Current GAF = _________ Highest GAF in the past year = ___________
Group Therapy (60-90 min) 90853
Wkly
Monthly
Qtrly
Other ______
Other ___________________________
Wkly
Monthly
Qtrly
Other ______
Treatment History: (please select all that apply)
Other _____________________________
Wkly
Monthly
Qtrly
Other ______
Previous Treatment in the Past 12 Months, excluding current course of treatment:
Type:
Mental Health
Substance Abuse
Both
None
Unknown
Please indicate type(s) of service provided BY OTHERS (select all that apply):
Outpatient
Partial/IOP
Inpatient
Residential
Group Home
Other
Medication Management
Indiv. Psychotherapy
Family Psychotherapy
Outcome:
Unknown
Improved
No Change
Worse
Group Therapy
Community Program(s)
Self Help Group(s)
Treatment Compliance (Non-Med):
Unknown
Poor
Fair
Good
Are the Patient’s family/supports involved in treatment?
Yes
No
Is the individual currently receiving disability benefits
Yes
No
Has Patient been evaluated by a psychiatrist:
Yes
No
Current Psychotropic Medications: Dosage Frequency Usually adherent?
Current Risk Assessment:
(Please select/circle one value for each type of risk
1.
YES
NO
Key: 0 = none; 1 = mild, ideation only; 2 = moderate, ideation with EITHER plan or history
2.
YES
NO
of attempts; 3 = severe, ideation AND plan, with either intent or means; na = not assessed)
3.
YES
NO
Patient’s risk to others:
0
1
2
3
na
Treating Provider’s Signature: _________________________________Date: ___________
Patient’s risk to self:
0
1
2
3
na
Patient’s risk to self:
0
1
2
3
na
Page 1 of 2 ValueOptions revised 11/08/2010
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