NEW DIRECTIONS BEHAVIORAL HEALTH FOR PHYSICIANS & ARNPS ONLY OUTPATIENT TREATMENT REQUEST FORM FOR BLUE CROSS (OTR) Request Form for BCBS o Outpatient Treatment Provider Info: FAX REQUEST TO (913) 982-8176 Name:__________________________________________ NPI# ______________________________________________ Date Provider Name Address:__________________________________________________ Phone#: _________________________________ Facility/Group Name Client Info: Address Name: ______________________________________ Insured ID#: ____________________DOB: ___________________ Phone Fax Diagnostic Formulation Provider NPI# Axis I: __________________________________ Axis II: _________________ Axis III: _____________________________ Client Name Axis IV: _________________________________ GAF: current ________ Past Year ________ Date of Birth Risk Severity Index None Mild Moderate Symptom Certificate No. Severity Index Severe Harm to self/others Substance Abuse Psychosis Medical Issues Insurance WNL Telephone Number Group No. Mild Depression/ Anxiety Social Functioning Impulsivity Axis I ADL’s/ Self Care Moderate Diagnosis Axis I Axis II Medication Information Has the member had a psychiatric medication evaluation? Current Medications and dosage Yes Axis IV No Yes No Unknown Axis III planned unknown Prescriber Medication Compliance Psychiatrist Severe ARNP ____________________________________ 90805 # Requested ________ ____________________________________ 90807 # Requested ________ ____________________________________ 90862 # Requested ________ PCP Axis V (GAF) Current/L Other Risk Rate the Member’s probab treatment OUTPATIENT 5 4 3 Rate the Member’s capacit ____________________________________ Other (specify) # Requested ____________ Treatment Information COMPLIANT 5 4 Expected Treatment (TX) Outcome: problem resolution symptom reduction maintenance 1. Provide treatment goals: ____________________________________________ TX modalities requested by you: individual family group ________________________________________________________________ medication management ________________________________________________________________ Frequency of TX requested: _____________________________ Estimated Sessions to TX completion: ___________ 2. Provide medication and dosage: ______________________________________ TX modalities provided by other providers: individual family ________________________________________________________________ group case mgmt medication mgmt Other resources utilized: EAP Community Support Groups disease management supported living ________________________________________________________________ Is the family/ primary support system involved in TX? Yes No none available Are you coordinating care with other behavioral health care providers? Yes refused Information on this form mayNo be CONFIDENTIAL, protected under the HIPAA-PRIVACY RULE, or otherw intended only for the use of the Provider and New Directions™. If the recipient of this information is n Yes No refused Are you coordinating care with the member’s primary care physician? employee or agent responsible for delivering it to the intended recipient, you are hereby on notice tha and privileged information. Treatment Plan, Progress, and Barriers If you have received this facsimile in error, please immediately notify the s original to the sender at the above fax number. ANY DISSEMINATION, DISTRIBUTION, OR COPYING OF EXCEPT IN COMPLIANCE WITH FEDERAL AND APPLICABLE STATE LAWS. _______________________________________________ Provider Signature Please FAX this request to: 816-237-2364 Mail to: NDBH, PO Box 1627, Topeka, KS 66601-1627 42-1 08/12 ____________________ Date For questions, please call: (800) 952-5906 Blue Cross and Blue Shield of Kansas is an independent licensee of the Blue Cross and Blue Shield Association. New Directions