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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