Document 140808

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 patient’s
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
PROVIDER’S 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.
PROVIDER’S 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.