OUTPATIENT TREATMENT REQUEST
BlueCross BlueShield
of Texas
(OTR) Effective 01/01/2011
Instructions: Please fill out and print, or print form and fill out legibly in black ink. Fax to BCBSTX at 877-361-7646. All fields in shaded areas are mandatory.
Request ID #:_________________________________________
Patient/Member Information
Member Name_____________________________________________
Patient Name__________________________________________________
Group #______________________________________________________
Patient DOB___________________________________________________
Subscriber # __________________________________________________
Provider Information (Individual and/or Group)
Provider Name_____________________________________________
Address _________________________________________________
City_________________________________________________________
State______________________________________ Zip_______________
NPI # _______________________________________________________
Fax #_________________________ Phone #________________________
Has the member been screened for possible substance use disorder? c Yes c No
DSM-IV or ICD-9 Diagnosis numeric and description
Primary Diagnosis
Axis I________________________________
Targeted Symptoms of Treatment:
Axis II _______________________________
_____________________________________________________
Axis III _______________________________
_____________________________________________________
Axis IV _______________________________
_____________________________________________________
Axis V Current ___________________________ Highest Past Year ________
_____________________________________________________
Current Treatment
Stage of Therapy: (Check one)
Initiation c
Continuation c
Maintenance c
Type of Psychotherapy
Goals for Treatment
Goal #1: ______________________________________________________________
c Cognitive Behavioral
c Dialectical Behavioral
Intervention for Goal #1 _____________________________________________________
c EMDR
Goal #2: ______________________________________________________________
c Interpersonal
Intervention for Goal #2 _____________________________________________________
c Psychoanalytic
Authorization should start on: ______________________________________________(date)
c Psychodynamic
c Psycho-educational
Anticipated Treatment Outcome:
c Supportive
c Discharge from Care
Date:__________________________
c Other (Specify):
c Transition to Maintenance Care
Date:__________________________
____________________________________
c Other ____________________________________________________________
The patient’s care is being coordinated with the following individuals: (Check all that apply)
PCP_______________ Psychiatrist _______________ Other Therapist _______________ Other _________________________________________
If no coordination with others, why?_________________________________________________________________________________________
Requested Treatment (Number and Frequency)
Current Medications
Modality and CPT Code
Req
Freq
Psychiatric Meds (Name/Dose)
Other Meds
________
________
Is this Patient on psychotropic meds for
90832 Individual, 30 min
c
________
________
condition being treated? c Yes c No
90833 Ind. with E/M, 30 min
c
________
________
_________________________________
_________________________________
90834 Individual, 45 min
c
________
________
_________________________________
_________________________________
90836 Ind. with E/M, 45 min
c
________
________
_________________________________
_________________________________
90837 Individual, 60 min
c
________
________
_________________________________
_________________________________
90847 Couple/Family
c
________
________
_________________________________
_________________________________
90853 Group
c
________
________
_________________________________
_________________________________
Other ______________
c
Additional Clinical Information:_____________________________________________________________________________________________
My signature confirms that I am providing the requested services:
Signature __________________________________________________________ Date ___________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
55583.0113