Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 57 views

    Outpatient Resume

    Uploaded by

    Abdul Gamal
    The document is an outpatient treatment report form containing fields for patient and provider information, diagnoses, current and past risk assessments, medications, treatment history, symptoms and functional impairment, substance abuse information if relevant, and the provider's continued treatment plan including modality and frequency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Outpatient Resume

    Uploaded by

    Abdul Gamal
    57 views1 page
    The document is an outpatient treatment report form containing fields for patient and provider information, diagnoses, current and past risk assessments, medications, treatment history, symptoms and functional impairment, substance abuse information if relevant, and the provider's continued treatment plan including modality and frequency.

    Original Description:

    outpatient

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document is an outpatient treatment report form containing fields for patient and provider information, diagnoses, current and past risk assessments, medications, treatment history, symptoms and functional impairment, substance abuse information if relevant, and the provider's continued treatment plan including modality and frequency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    57 views1 page

    Outpatient Resume

    Uploaded by

    Abdul Gamal
    The document is an outpatient treatment report form containing fields for patient and provider information, diagnoses, current and past risk assessments, medications, treatment history, symptoms and functional impairment, substance abuse information if relevant, and the provider's continued treatment plan including modality and frequency.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    OUTPATIENT TREATMENT REPORT

    INSTRUCTIONS: Please print all information. Fax completed form to (877) 521-4787 (toll-free).
    PATIENT Name
    PROVIDER Individual and/or Group
    Name

    ID #

    Tax ID #

    Address

    DOB

    License #

    City

    State

    Phone #
    ZIP

    ICD-9 DIAGNOSIS numeric + description


    Axis I

    Fax #

    MEDICAL CONDITIONS
    None

    Chronic Pain

    Axis II

    Asthma/COPD

    Dementia

    Axis III

    Cancer

    Diabetes

    Axis IV

    Cardiovascular Problems

    Obesity

    Axis V

    Other

    current
    CURRENT RISK ASSESSMENT
    Suicidal
    Ideation
    Homicidal
    Ideation
    MEDICATIONS
    Medication

    highest past year


    Plan
    Plan

    Intent
    Intent

    Psychotropic

    Hx of harming self
    Hx of harming others

    Medical

    N/A
    N/A

    Prescribing MD

    PCP

    Psychiatrist

    Other

    If affective or psychotic disorder is present and


    no medications are prescribed, please explain:
    COORDINATION OF CARE
    TREATMENT HISTORY
    I have communicated with patients
    Inpatient:
    Within past yr
    PCP
    Specialist
    Psychiatrist
    Therapist
    Outpatient:
    Within past yr
    SYMPTOMS and FUNCTIONAL IMPAIRMENT If present, check degree
    On Disability?
    Yes
    Mild Moderate Severe

    DESIRED OBSERVABLE OUTCOMES

    Anthem Blue Cross P.O. Box 600188 San Diego, CA 92160

    More than 3 yrs ago


    More than 3 yrs ago

    Mild Moderate Severe

    Anxiety
    Hopelessness
    Decreased Energy
    ADLs
    Delusions
    Family/Relationships
    Depressed Mood
    Inattention
    Hallucinations
    Irritability/Mood instability
    Hyperactivity
    Impulsivity
    Substance Abuse/Dependence
    Active
    In Remission
    If Substance Abuse is current or focus of treatment, complete the information below:
    Substance of Choice
    Amount
    Frequency
    Alcohol
    Marijuana
    Heroin
    Opioids
    Cocaine
    list
    Methamphetamine
    Prescr. Drugs
    Inhalants
    list

    PROVIDERS CONTINUED TREATMENT PLAN


    Modality and CPT Code
    Frequency
    Individual 90832
    ____ x per
    wk
    Individual 90834
    ____ x per
    wk
    Individual 90833*
    ____ x per
    wk
    Individual 90836*
    ____ x per
    wk
    Couple/Family 90847
    ____ x per
    wk
    Group 90853
    ____ x per
    wk
    Other ________________
    ____ x per
    wk
    *MDs or Nurse Practitioners only

    1 to 3 yrs ago
    1 to 3 yrs ago
    No

    Mild Moderate Severe

    Obsessions/Compulsions
    Significant Weight Change
    Panic Attacks
    Sleep Disturbance
    Physical Health
    Work/School

    Date of Last Use


    Is patient currently participating in a
    community-based support group?
    (Includes AA, NA, etc.)
    Yes
    No
    If Yes, frequency of attendance:
    Is there a sponsor?
    Yes

    Patient agrees with treatment goals

    mo
    mo
    mo
    mo
    mo
    mo
    mo

    yr
    yr
    yr
    yr
    yr
    yr
    yr

    Anticipated
    Completion
    ____ mo(s)
    ____ mo(s)
    ____ mo(s)
    ____ mo(s)
    ____ mo(s)
    ____ mo(s)
    ____ mo(s)

    Yes

    No
    No

    TREATMENT PROGRESS
    Level of improvement to date
    Minor
    Moderate
    Major
    No progress to date
    Maintenance tx of chronic condition
    # of sessions provided to date
    Start date for new authorization
    My signature confirms that I am providing the requested services.

    PROVIDERS SIGNATURE

    DATE

    CA-2012-12
    Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue
    Cross name and symbol are registered marks of the Blue Cross Association.

    You might also like