This form is meant to facilitate communication about Healthy Pathwaysbetween the Healthy Pathways case manager and South Country. The form is used to:
Provide initial notification to South Country of a member receiving this service
Verify eligibility for this service (This form is not intended to be a substitute for a comprehensive diagnostic assessment completed by a mental health professional.)
Requestcommunication for a completed Diagnostic Assessment within 6 months of initial service date
Provide notification of SMI/SPMI restart verification
Provide notification of SMI/SPMI reinstate verification
Provide DTR notification / OutcomeMeasuresfor this service
- Member Information
Member Name
PMI #
DOB
Member Address, City, State, Zip
- Case Manager Information
Case Manager
Organization Name
Organization Address, City, State, Zip
Case Manager Phone
Case Manager Fax
- Reason for communication (check all that apply)
Initial Notification
Initial SMI/SPMI Verification / SMI/SPMI Restart Verification
SMI/SPMI Reinstate Verification / DTR Notification
Outcome Measure Notification
- Service Dates
Start Date: / End Date:
- SMI / SPMI Verification Information
Type of Record Verification (check all that apply): / Date of Record Verification:
Psychiatric Hospital Admission
Hospital Discharge Summary
Diagnostic Assessment
Other, specify:
Requesting extension to get completed DA as unable to get completed within 6 months of initial service date. DA scheduled to be completed by:
Reason DA unable to be completed within 6 months of request for Alternative Service:
Diagnoses
Describe Symptoms:
OR
Formal Diagnoses, if known:
Name of Mental Health Professional making determination
Qualifications of Mental Health Professional
LP LMFT LICSW LPP LPCC CNS-MH Psychiatrist Psychiatric NP
Name of Agency record obtained from
Agency Address, City, State, Zip
Agency Phone
Agency Fax
Select appropriate verification choice: / Date:
Original SMI / SPMI Verification
SMI / SPMI Restart Verification
SMI / SPMI Reinstate Verification
- Signatures – Case manager and Clinical Supervisor who verified SMI / SPMI status
Signature: / Date:
Case Manager:
Clinical Supervisor:
- Recommendations for Goals/other services (check all that apply):
Mental Health Symptoms / Self-Care / Independent Living Capacity
Mental Health Service Needs / Physical Health
Use of Drugs/Alcohol / Medication Concerns
Educational Functioning / Dental Health
Vocational Functioning / Obtain/Maintain Financial Assistance
Social Functioning / Obtain/Maintain Housing
Interpersonal Functioning / Using Transportation
Other, specify:
- Member Reported Outcomes
I would describe my current status as: / Strongly Agree / Agree / Disagree / Strongly Disagree / NA
Member
(Mbr) / Case Mgr (CM) / Mbr / CM / Mbr / CM / Mbr / CM / Mbr / CM
I deal effectively with daily problems.
My housing situation is stable.
I can take care of my needs.
I know where to go for help.
Status of overall health / Excellent / Very Good / Good / Fair / Poor
Mbr / CM / Mbr / CM / Mbr / CM / Mbr / CM / Mbr / CM
In general would you say your health and well-being is…?
Member Narrative:
Case Manager Narrative:
- Denial, Reduction, Termination of Service
Graduated from program, service no longer needed
Member opts to discontinue this service
Transitioned to other services: / MH-TCM ARMHS ACT Waiver Program
Long-Term Care Facility Community Support Program
Chemical Dependency Treatment Other, specify:
No longer eligible: Dis-enrolled from South Country Health Alliance Jail Deceased
Recommended date for closing service:
X. Assurances
I, Case Manager, attest that I have given the member written information that includes my name and how to contact me.
I, Case Manager, have given the member South Country’s Appeal Information and Member Rights.
Submit this form either by faxing it to (507) 431-6329 or by secure email to .
Thank you.
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