Progress Report / Authorization Request Form
*Provider Name: Telephone Number:
Group Practice: Fax Number:
Date Completed: / / Email Address:
*CHIPA Cert ification Number: *Insurance Code (From Cert ification Letter)
Payor Reference ID Number: AT MH2 PB TM
First Date of Treatment: / / Last Date of Treatment: / /
DSM IV Diagnosis Code(s) or Description
*Axis I
Secondary
Axis II
  
Axis III
Axis IV
 None Mild Moderate Severe
Axis V
 Current    Last Reported     Highest Past Year
PLEASE CHECK ALL THE APPROPRIATE BOXES FOR EACH SECTION
Treatment History Substance Abuse History
Is compliance with medical treatment a problem? Yes No Does the patient currently have a substance abuse problem? Yes No
How many times has the patient been hospitalized for a psychiatric condition? None 1 2 3 Is the patient receiving, or has received treatment for substance abuse? Yes No
if the hospitalization occurred within the past 12 months, how long ago was the most recent episode?
0-3 Mos
4-6 Mos
7-12 Mos
What type(s) of treatment has the patient received for substance abuse?
12 Step
OP
IP
NA
Functional Impairments and Symptoms Medications and Coordination of Care
 
None
Mild
Mod
Sev
Impaired Family Relationships
Impaired Physical Well Being
Impaired Work
Suicidal Ideation
Homicidal Ideation
Binging/ Purging
Psychotic Symptoms
SelfMutilation
Inattention
Hyperactivity
Destruction of Property
Fire Setting
Academic Failure
Does patient have referral for med eval? Yes No
Is the patient currently taking meds? Yes No
if NO PLEASE SKIP TO FINAL QUESTION
Who is Prescribing?
I am prescribing     Psychiatrist     PCP
Other
Types of Medication
Anti-Depresessant Anti-Anxiety
Anti-Psychotic Sedative-Hypnotic
Mood Stabilizer Stimulant
Other
Is patient compliant with medication? Yes No
if you are not the prescribing provider have you communicated with him/her? Yes No
Have you communicated with PCP? Yes No
 
Narrative Progress Note (optional):
Authorization Request
Total Sessions to Date: Additional Sessions Required: Or Treatment Terminated:
* From Start of treatment
CPT Code Requested 90862 90805 90806 90807 90847 90853
Other:

 

 

   

 
  About Us l Solutions l Members l Providers l Employment l Contact Us    Copyright 2007 Comprehensive Behavioral Health Management