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.