Medication Evaluation / Management Treatment Plan





NO TREATMENT PLAN IS REQUIRED IF TREATMENT IS COMPLETED WITHIN THE INITIAL SET OF AUTHORIZED SESSIONS. Initial report must be submitted from Mines secure forms website at www.minesandassociates.com and click on the "Service Providers" tab prior to the use of the last authorized session if and only if you need additional sessions.


Client Name: *   
Mines Client #:  
Employer:  
Insured's Name: *   
Insured's Social Security #: *   

 

This treatment plan is for medication evaluation and/or medication management only. If a psychotherapy referral is indicated, Mines & Associates must be notified. This treatment plan must be submitted prior to the submission of any insurance claim. No services can be authorized otherwise.

 

Date for Authorization of Services to Begin: *   MM/DD/YYYY     
Current Diagnosis: *   

 

MEDICATION MANAGEMENT PLAN:
Medication: *   
Dosage:  
Frequency of Sessions:  
Duration of Sessions:  

 

Additional Patient Recommendations:
(e.g. client would benefit from psychotherapy, psychoeducational programming, etc.)
   
Provider: *   
Email:  
Phone: *   

When you click "Submit Form" below, a confirmation page will display. You can, at that time, print a copy of this completed form for your records (At the top of your browser, click on "File" and then "Print".) or cut and paste it into the application of your choosing.

                  

 

MINES & Associates 10367 West Centennial Road Littleton, CO 80127 800.873.7138
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