Adult Psychiatric Clinical Service Form Page 2
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4Physician and Facility Information
¨ Initial Request
¨ Concurrent Review
Ordering Physician/Practitioner: ___________________________ Provider Number/NPI: ___________________
Phone Number: ______________________________Fax Number:_____________________________________
Date of Order: ________________________________________
Certificate of Medical Necessity:
1
Certificate of Need (CON): Date _____________________________________ Time ____________________
st
2
nd
CON: Date _____________________________________________________ Time ____________________
Facility Name: _________________________________________ Provider Number/NPI: __________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
Phone Number: ______________________________Fax Number:_____________________________________
Utilization Review (UR) Contact: ________________________________________________________________
UR Contact #: _______________________________________________________________________________
Requested Start Date: ___________________________________
Clinical Information
Presenting Problem (behavioral description of acuity; describe any attempt, rescue, self-rescue, lethality, medical
treatment received): _________________________________________________________________________
__________________________________________________________________________________________
Precipitant (What stressor led to this treatment request? Why now?) ___________________________________
__________________________________________________________________________________________
q YES q NO
*Suicidal Ideation?
Plan: _____________________________________________________________________________________
__________________________________________________________________________________________
Intent: ____________________________________________________________________________________
__________________________________________________________________________________________
Means: ___________________________________________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
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