Behavioralhealth Levelofcarerequestform
BEHAVIORALHEALTH—LEVELOFCAREREQUESTFORM
For Eating Disorders level of care requests, complete the relevant supplemental section on page 2.
Please type an “x”or type content as needed in the gray boxes only.
NOTE: Text boxes will not expand beyond the space available
MEMBER NAME:DOB (MM/DD/YYYY): / Gender: Other: / Male / Female / Other :
GENDER:
Insurer: / Policy#:
Requesting Clinician/Facility:
Phone#: / NPI/TIN#:
Servicing Clinician/Facility:
Phone#: / NPI/TIN#:
CurrentlyinanER: / Yes / No / DateandTimeofRequest (MM/DD/YYYY):
ServiceDateforRequest (MM/DD/YYYY):
LEVEL OF CARE REQUESTED
Inpatient / PartialHospitalization / CommunityStabilization/Treatment: / ( / ICBAT / CBAT / CCS/CSU)
Residential / OutpatientPsychotherapy(except90837/90838) / 90837/90838: / ( / ACT / CBT / CognitiveProcessing
DBTE / EMDR / Exposure / FunctionalFamily / PCIT / IPT / Other:)
FamilyStabilization / Other:
SERVICE TYPE
Behavioral Health / BHinGeneralHospital / DualDiagnosis / EatingDisorder
CHIEFCOMPLAINT/REASONFORREQUEST/DIAGNOSES
Chief Complaint/Reason for Request(Frequency,intensity,durationofsymptoms) / mild / moderate / severe
acutelylifethreatening: / Arethereanyfunctionalimpairments? / Yes / No
Medications: / None / antidepressant / antianxiety / antipsychotic / moodstabilizer
stimulant / Other:
PrimaryPsychiatricdiagnosis: / ICD/DSMCode:
SecondaryPsychiatricdiagnosis: / ICD/DSMCode:
SubstanceUseDisorderdiagnosis: / ICD/DSMCode:
Relevantactivemedicalproblems? / Yes / No / Medicallycleared? / Yes / No
Needsfurtherevaluation/intervention? / Yes / No
RelevantActiveMedicaldiagnoses: / ICD Code:
PriorAdmissions: / Yes / No / Unknown / INPATIENT: / #oftimes / mostrecent (mm/dd/yyyy)
SUBSTANCEUSE/DETOX: / #oftimes / mostrecent (mm/dd/yyyy) / OTHER:(specify) / #oftimes / mostrecent (mm/dd/yyyy)
MEDICAL/PSYCHOSOCIALRISKSANDFUNCTIONALIMPAIRMENTS(selectallthatapplytothecurrentrequest):
1.Suicidal: / Current Ideation / Active Plan / Current Intent / Access to Lethal Means / None
Section 12 / Current Suicide Attempt / Prior Suicide Attempt (<1 year) Explain:
2.Homicidal/Violent: / Current Ideation / Active Plan / Current Intent / Access to Lethal Means / None
Current Threat to Specific Person / Prior Violent Acts (<1 year) Explain:
3.Self-Care
/ADLs: / mild / moderate / severe / acutelylife-threatening Explain:
HighestandLowest LevelsofFunctioning(<1 year):
4.Self-InjuriousBehavior: / mild / moderate / severe / acutelylife-threateningExplain:
Agitated/AggressiveBehavior: / mild / moderate / severe / acutelylife-threateningExplain:
5.MedicationAdherence: / Yes / No / Unknown / OtherTreatmentAdherence: / Yes / No / Explain:
6.LegalIssues,Court/DYSInvolvement: / Yes / No / Explain:
7.EmploymentRisks: / employed / employmentatrisk / on/requestingmedicalleave / disabled
unemployed / Other / Explain:
8.Psychosocial/Homeenvironment: / supportive / neutral / directlyundermining / homerisk/safetyconcerns
homeless / livesalone / married / single / divorced / separated / dependents
Other / Explain:
9.AdditionalConcerns: / Yes / No / Explain:
10.OutpatientBH/SUDtreatmentinplace? / Yes / No / Unknown, Havetheoutpatienttreatersbeencontacted? / Yes / No
BHLevelofCare:Supplemental—forEatingDisorders
EatingDisorderslevelofcarerequests(completethefollowing):LevelofCare:
InpatientEatingDisordersSpecialty Unit(medicallyunstable) / PartialHospitalEatingDisorders Program(weekdays,9–2or9–5)
Acute ResidentialEatingDisorders Unit / IntensiveOutpatientEatingDisordersProgram(severaldays per week, afewhours)
PartialHospitalEatingDisordersProgram(sevendays perweek) / OutpatientEatingDisorderProgram
Height: / Weight: / BMI: / %IBW:
Highestweight: / Lowestweight: / Weightchangeinonemonth:
OrthostaticVitals: / sittingBP: / / / PR: / standingBP: / / / PR:
Labs: / Potassium: / Sodium: / Relevant abnormallabs:
Abnormal:
EKG: / Yes / No
Medical Evaluation: / Yes / No / If yes, when
Recentneedfor IVhydration: / Yes / No / If yes, when
CurrentSymptoms: / dizziness / fainting / palpitations / shortnessofbreath
amenorrhea / coldintolerance / vomitingblood
CurrentBehaviors: / binging / purging / restricting / overexercising / None
CurrentAbuseof: / laxatives / diuretics / dietpills / ipecac / None
Specifyotherpertinentsymptoms,behaviors,orhigh-riskpresentations:
*Thisformisintendedforfully-insuredplansonly.Notallcarriersrequirepriorauthorizationfortheaboveservices;notalllevelsofcareareavailableinmemberbenefitplans.Providersshouldconsultthehealthplan’scoveragepoliciesandmemberbenefits.
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