Name:
REQUEST FOR PROGRAM REVIEW COMMITTEE INTERIM APPROVALDate of Request FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????Name: FORMTEXT ????? DDS # FORMTEXT ????? DOB: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????Residence: FORMTEXT ?????Agency: FORMTEXT ?????Case Manager/Contact Person: FORMTEXT ?????Fax # (To fax approval): FORMTEXT ?????DSM-5 DiagnosisClinical Disorders FORMTEXT ????? FORMTEXT ?????Cognitive/Personality Disorders FORMTEXT ????? FORMTEXT ?????General Medical Conditions FORMTEXT ????? FORMTEXT ?????Prescriber: FORMTEXT ?????Date last seen by Prescriber FORMTEXT ?????List Behaviors of Concern1. FORMTEXT ?????4. FORMTEXT ?????2. FORMTEXT ?????5. FORMTEXT ?????3. FORMTEXT ?????6. FORMTEXT ?????List Target Behaviors1. FORMTEXT ?????4. FORMTEXT ?????2. FORMTEXT ?????5. FORMTEXT ?????3. FORMTEXT ?????6. FORMTEXT ?????List all current medications; List new medication/dose firstCurrentDoseProposed RangeStatus: Check OneC = Current (Has PRC approval)A = Add (Needs PRC approval)1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX ARationale for New Medication(s) or Dose Change(s): FORMTEXT ?????____________________________________________________________________________________ FORMTEXT ?????____________________________________________________________________________________ FORMTEXT ?????____________________________________________________________________________________Individual or Guardian Consent FORMCHECKBOX Yes FORMCHECKBOX NoInterim Review/ApprovalPRC Psychiatrist _________________Date FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? SignaturePRC Liaison _________________Date FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? SignatureRegional Director _________________Date FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? SignatureDate Faxed to Agency: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????Date for Full PRC Review: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????Date Material Due: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? ................
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