Provider Express



BEHAVIORAL HEALTH — LEVEL OF CARE REQUEST FORMFor Eating Disorders level of care requests, complete the relevant supplemental section on page 2.Please type an “x” or type content as needed in the gray boxes only.NOTE: Text boxes will not expand beyond the space availableMEMBER NAME: FORMTEXT ?????DOB (MM/DD/YYYY): FORMTEXT ?????Gender: Other: FORMTEXT ?????Male FORMTEXT ?????FemaleOther : FORMTEXT ?????GENDER:Insurer: FORMTEXT ?????Policy #: FORMTEXT ?????Requesting Clinician/Facility: FORMTEXT ?????Phone #: FORMTEXT ?????NPI / TIN#: FORMTEXT ?????Servicing Clinician/Facility: FORMTEXT ?????Phone #: FORMTEXT ?????NPI / TIN#: FORMTEXT ?????Currently in an ER: FORMTEXT ?????Yes FORMTEXT ?????NoDate and Time of Request (MM/DD/YYYY): FORMTEXT ?????Service Date for Request (MM/DD/YYYY): FORMTEXT ?????LEVEL OF CARE REQUESTED FORMTEXT ????? Inpatient FORMTEXT ?????Partial Hospitalization FORMTEXT ?????Community Stabilization/Treatment: ( FORMTEXT ????? ICBAT FORMTEXT ?????CBAT FORMTEXT ?????CCS/CSU) FORMTEXT ?????Residential FORMTEXT ?????Outpatient Psychotherapy (except 90837/90838) FORMTEXT ?????90837/90838:( FORMTEXT ?????ACT FORMTEXT ?????CBT FORMTEXT ????? Cognitive Processing FORMTEXT ?????DBTE FORMTEXT ?????EMDR FORMTEXT ?????Exposure FORMTEXT ?????Functional Family FORMTEXT ?????PCIT FORMTEXT ?????IPT FORMTEXT ?????Other: FORMTEXT ?????) FORMTEXT ?????Family Stabilization FORMTEXT ?????Other: FORMTEXT ?????SERVICE TYPE FORMTEXT ?????Behavioral Health FORMTEXT ?????BH in General Hospital FORMTEXT ?????Dual Diagnosis FORMTEXT ?????Eating DisorderCHIEF COMPLAINT/REASON FOR REQUEST/DIAGNOSESChief Complaint/Reason for Request (Frequency, intensity, duration of symptoms) FORMTEXT ?????mild FORMTEXT ?????moderate FORMTEXT ?????severe FORMTEXT ?????acutely life threatening: FORMTEXT ?????Are there any functional impairments? FORMTEXT ?????Yes FORMTEXT ?????NoMedications: FORMTEXT ?????None FORMTEXT ?????antidepressant FORMTEXT ?????antianxiety FORMTEXT ?????antipsychotic FORMTEXT ?????mood stabilizer FORMTEXT ?????stimulant FORMTEXT ?????Other: FORMTEXT ?????Primary Psychiatric diagnosis: FORMTEXT ?????ICD/DSM Code: FORMTEXT ?????Secondary Psychiatric diagnosis: FORMTEXT ?????ICD/DSM Code: FORMTEXT ?????Substance Use Disorder diagnosis: FORMTEXT ?????ICD/DSM Code: FORMTEXT ?????Relevant active medical problems? FORMTEXT ?????Yes FORMTEXT ?????NoMedically cleared? FORMTEXT ?????Yes FORMTEXT ?????NoNeeds further evaluation/intervention? FORMTEXT ?????Yes FORMTEXT ?????NoRelevant Active Medical diagnoses: FORMTEXT ?????ICD Code: FORMTEXT ?????Prior Admissions: FORMTEXT ?????Yes FORMTEXT ?????No FORMTEXT ?????UnknownINPATIENT:# of times FORMTEXT ?????most recent (mm/dd/yyyy) FORMTEXT ?????SUBSTANCE USE/DETOX:# of times FORMTEXT ?????most recent (mm/dd/yyyy) FORMTEXT ?????OTHER: (specify) FORMTEXT ?????# of times FORMTEXT ?????most recent (mm/dd/yyyy) FORMTEXT ?????MEDICAL/PSYCHOSOCIAL RISKS AND FUNCTIONAL IMPAIRMENTS (select all that apply to the current request):Suicidal: FORMTEXT ?????Current Ideation FORMTEXT ?????Active Plan FORMTEXT ?????Current Intent FORMTEXT ?????Access to Lethal Means FORMTEXT ?????None FORMTEXT ?????Section 12 FORMTEXT ?????Current Suicide Attempt FORMTEXT ?????Prior Suicide Attempt (<1 year) Explain: FORMTEXT ?????Homicidal/Violent: FORMTEXT ?????Current Ideation FORMTEXT ?????Active Plan FORMTEXT ?????Current Intent FORMTEXT ?????Access to Lethal Means FORMTEXT ?????None FORMTEXT ?????Current Threat to Specific Person FORMTEXT ?????Prior Violent Acts (<1 year) Explain: FORMTEXT ?????Self-Care/ADLs: FORMTEXT ?????mild FORMTEXT ?????moderate FORMTEXT ?????severe FORMTEXT ?????acutely life-threatening Explain: FORMTEXT ?????Highest and Lowest Levels of Functioning (<1 year): FORMTEXT ?????Self-Injurious Behavior: FORMTEXT ?????mild FORMTEXT ?????moderate FORMTEXT ?????severe FORMTEXT ?????acutely life-threatening Explain: FORMTEXT ?????Agitated/Aggressive Behavior: FORMTEXT ?????mild FORMTEXT ?????moderate FORMTEXT ?????severe FORMTEXT ?????acutely life-threatening Explain: FORMTEXT ?????Medication Adherence: FORMTEXT ?????Yes FORMTEXT ?????No FORMTEXT ?????Unknown FORMTEXT ?????Other Treatment Adherence: FORMTEXT ?????Yes FORMTEXT ?????NoExplain: FORMTEXT ?????Legal Issues, Court/DYS Involvement: FORMTEXT ?????Yes FORMTEXT ?????NoExplain: FORMTEXT ?????Employment Risks: FORMTEXT ?????employed FORMTEXT ?????employment at risk FORMTEXT ?????on/requesting medical leave FORMTEXT ?????disabled FORMTEXT ?????unemployed FORMTEXT ?????OtherExplain: FORMTEXT ?????Psychosocial/Home environment: FORMTEXT ?????supportive FORMTEXT ?????neutral FORMTEXT ?????directly undermining FORMTEXT ?????home risk/safety concerns FORMTEXT ?????homeless FORMTEXT ?????lives alone FORMTEXT ?????married FORMTEXT ?????single FORMTEXT ?????divorced FORMTEXT ?????separated FORMTEXT ?????dependents FORMTEXT ?????OtherExplain: FORMTEXT ?????Additional Concerns: FORMTEXT ?????Yes FORMTEXT ?????NoExplain: FORMTEXT ?????Outpatient BH/SUD treatment in place? FORMTEXT ?????Yes FORMTEXT ?????No FORMTEXT ?????Unknown, Have the outpatient treaters been contacted? FORMTEXT ?????Yes FORMTEXT ?????NoBH Level of Care: Supplemental — for Eating DisordersEating Disorders level of care requests (complete the following):Level of Care: FORMTEXT ?????Inpatient Eating Disorders Specialty Unit (medically unstable) FORMTEXT ?????Partial Hospital Eating Disorders Program (weekdays, 9–2 or 9–5) FORMTEXT ?????Acute Residential Eating Disorders Unit FORMTEXT ?????Intensive Outpatient Eating Disorders Program (several days per week, a few hours) FORMTEXT ?????Partial Hospital Eating Disorders Program (seven days per week) FORMTEXT ?????Outpatient Eating Disorder ProgramHeight: FORMTEXT ?????Weight: FORMTEXT ?????BMI: FORMTEXT ?????% IBW: FORMTEXT ?????Highest weight: FORMTEXT ?????Lowest weight: FORMTEXT ?????Weight change in one month: FORMTEXT ?????Orthostatic Vitals: sitting BP: FORMTEXT ????? / FORMTEXT ?????PR: FORMTEXT ?????standing BP: FORMTEXT ????? / FORMTEXT ?????PR: FORMTEXT ?????Labs:Potassium: FORMTEXT ?????Sodium: FORMTEXT ?????Relevant abnormal labs: FORMTEXT ?????Abnormal: FORMTEXT ?????EKG: FORMTEXT ?????Yes FORMTEXT ?????NoMedical Evaluation: FORMTEXT ?????Yes FORMTEXT ?????NoIf yes, when FORMTEXT ?????Recent need for IV hydration: FORMTEXT ?????Yes FORMTEXT ?????NoIf yes, when FORMTEXT ?????Current Symptoms: FORMTEXT ????? FORMTEXT ?????dizziness FORMTEXT ????? FORMTEXT ????? fainting FORMTEXT ????? FORMTEXT ?????palpitations FORMTEXT ????? FORMTEXT ?????shortness of breath FORMTEXT ????? FORMTEXT ?????amenorrhea FORMTEXT ????? FORMTEXT ?????cold intolerance FORMTEXT ????? FORMTEXT ?????vomiting bloodCurrent Behaviors: FORMTEXT ?????binging FORMTEXT ?????purging FORMTEXT ????? restricting FORMTEXT ?????over exercising FORMTEXT ????? NoneCurrent Abuse of: FORMTEXT ?????laxatives FORMTEXT ?????diuretics FORMTEXT ?????diet pills FORMTEXT ?????ipecac FORMTEXT ?????NoneSpecify other pertinent symptoms, behaviors, or high-risk presentations: FORMTEXT ?????* This form is intended for fully-insured plans only. Not all carriers require prior authorization for the above services; not all levels of care are available in member benefit plans. Providers should consult the health plan’s coverage policies and member benefits.2 ................
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