PPO Managed Care




 

 

Today's Date: *  MM/DD/YYYY   
 
Client Name: *  
Client's Employer / Organization #: *  
Insured's Name: *  
Insured's SS#: *  
Mines Client #: *  

 

CLINICAL INFORMATION: *
 
(Please indicate chief complaint, including frequency, intensity and duration of problem. Include all issues pertaining to substance abuse, mood disorders, psychosocial stressors, impulse control issues and relevant family history)
DIAGNOSIS: (DSM-IV)
Code Terminology
Axis I (a): *  
 
Axis I (b):
Axis II:
Axis III:
Axis IV:
Psychosocial Stressors:
Axis V:       Current GAF: *     Highest GAF Past Year: 

 

CURRENT MEDICATIONS:
Medications: *
 
Prescribed By:

 

 

TREATMENT GOALS/PLANNED INTERVENTIONS:
*Treatment Goals: - Expressed in measurable terms of frequency, intensity and duration as indicated.
  *Treatment Goals  
1 *
 
 
2  
3  
4  
 
TYPE OF TREATMENT PROVIDED (SELECT ONE): *
(**NOTE: Not all types of treatment are covered benefits through all insurance plans.  It is the provider's responsibility to verify benefits prior to initiating treatment.)
  Individual Therapy 
  Marital/Family Therapy 
  IOP (Mental Health or Chemical Dependency)
  Group Therapy
  Other (please specify below)
 
   
FREQUENCY OF SESSIONS *
Weekly
Biweekly 
Monthly
Other
 
   
Are you requesting additional sessions? *    Yes      No
 
If YES Indicate the number of sessions needed to complete this episode of care
 
(In most cases, a maximum of 8 sessions can be approved per authorization.)
    
If YES Enter date you need the new authorization to begin.
 
  (Please utilize all previous sessions authorized and specify here the date
for additional sessions to begin.)
   
**Please Note: Authorizations will not be backdated by more than 30 days**
 
Provider Name: *   
Practice Name: *   
Phone: *   
Fax:

Email: *

  
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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