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Medication Management Form

This document is a request form to reauthorize psychiatric medication management and therapy for a patient. It requests information such as the patient's symptoms, functional impairments, current medications, treatment plan, and progress. The treatment plan includes the patient's primary and secondary diagnoses, treatment goals and interventions, and progress toward meeting those goals. This information will be used to determine if continuing mental health care is medically necessary.

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Olrac Agairdam
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90 views3 pages

Medication Management Form

This document is a request form to reauthorize psychiatric medication management and therapy for a patient. It requests information such as the patient's symptoms, functional impairments, current medications, treatment plan, and progress. The treatment plan includes the patient's primary and secondary diagnoses, treatment goals and interventions, and progress toward meeting those goals. This information will be used to determine if continuing mental health care is medically necessary.

Uploaded by

Olrac Agairdam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Mental Health Service

Psychiatric Medication Management (with Therapy)


Reauthorization Request
>> Incomplete forms may delay reauthorization << >> One form per patient <<
Please fax completed form to the Mental Health Access Center(MHAC) fax number listed below.
MHAC Fax: 206-630-1683 / Phone: 206-630-1680 or toll-free 1-888-287-2680
Mailed forms are accepted as well: Kaiser Permanente, MHAC, P.O. Box 34799, Seattle WA 98124-1799
Provider Name: Today’s Date:
Agency: Consumer Name:
Phone Number: Consumer Number:
Fax Number: Date of Birth:
TIN:
*** If you need additional space please attach separate notes to this form. Thank you. ***
Date Current Episode of Care Began:
1. Suicidal/ Homicidal Ideation/ Thoughts of Serious Self Harm: Current: Yes No Past: Yes No
Current Suicide Plan: Yes No Current Suicide Intent: Yes No Past Attempts: Yes No
Current Homicide Plan: Yes No Current Homicide Intent: Yes No Past Attempts: Yes No
If “yes” to any Suicidal/Homicidal symptoms, please address in Treatment Plan, below.
2. Does the patient have an alcohol/substance use problem? Yes No
Has the patient been referred for treatment? Yes Yes, but patient declined No
3. Functional Impairments: (Current Impact of symptoms on functioning)
None Mild Moderate Severe Response Description
to Treatment*
Social
Psychological
Physical Health / Self Care
Work/school
*Response to Treatment: (I) Improving, (NC) No Change, (D) Declining
4. Is patient taking psychotropic medication(s)? Yes No Not Recommended Patient Declined
If yes, please describe: anti-depressant mood stabilizer anti-anxiety psycho-stimulant
anti-psychotic other don’t know
If patient is taking medications, who is prescribing them? Psychiatrist ARNP Primary Care Physician

Other ________________________________ Name of Provider __________________________________________

Have you communicated with: Patient’s Treating Prescriber? Yes No N/A

5. Have you communicated with the Patient’s Primary Care Physician? Yes No
6. Current Frequency of Visits: Once/week Twice/month Once/month Other
Planned Frequency of Visits: Once/week Twice/month Once/month Other

7. Number & Type (CPT Codes) of Additional Sessions Requested for the next 12 months

This information can be disclosed only with written consent of the person to whom it pertains or is otherwise
CONFIDENTIAL permitted by such regulations (Uniform Health Information Act Title 70.02)

Mental Health Reauthorization Request - bhsMentalHealthReauthRequest Revised 20181010


Treatment Plan
Please Note: In order for GHC to authorize continuing mental health care, treatment needs to be medically necessary, as determined
by review of clinical and treatment information provided/available and Medical Necessity Criteria.

Primary Diagnosis: Code: ________ DSM ICD-10


Outline or Describe Associated Symptoms being treated:

Duration of Symptoms being treated: <30 Days 1-6 Months 7-12 Months >1 Year
Current Symptom Severity: None Mild Mild-Mod Moderate Mod-Severe Severe
Goal (Specific, Measurable):

As Measured by:

Treatment Modality: Med Mngmt CBT DBT IPT Other


Current Treatment Interventions to Meet Goal (Specific; Frequency and Duration)

Outline Progress towards goal (including any changes in symptoms and response to treatment as measured by the
method outlined above)

Current Status: Resolved Significant Progress Moderate Progress Little Progress No Progress Declining
If patient is not progressing toward meeting therapeutic goals:
1. Describe reason for lack of progress:

2. What changes in treatment (Treatment Modality, Specific, Measurable Goals and Interventions) are being made to
help patient progress in treatment?

This information can be disclosed only with written consent of the person to whom it pertains or is otherwise
CONFIDENTIAL permitted by such regulations (Uniform Health Information Act Title 70.02)

Mental Health Reauthorization Request - bhsMentalHealthReauthRequest Revised 20210615


=================================================================================

Secondary Diagnosis: Code: ________ DSM ICD-10


Outline or Describe Associated Symptoms being treated:

Duration of Symptoms being treated: <30 Days 1-6 Months 7-12 Months >1 Year
Current Symptom Severity: None Mild Mild-Mod Moderate Mod-Severe Severe
Goal (Specific, Measurable):

As Measured by:

Treatment Modality: Med Mngmt CBT DBT IPT Other


Current Treatment Interventions to Meet Goal (Specific; Frequency and Duration)

Outline Progress towards goal (including any changes in symptoms and response to treatment as measured by the
method outlined above)

Current Status: Resolved Significant Progress Moderate Progress Little Progress No Progress Declining
If patient is not progressing toward meeting therapeutic goals:
1. Describe reason for lack of progress:

2. What changes in treatment (Treatment Modality, Specific, Measurable Goals and Interventions) are being made to
help patient progress in treatment?

Person Completing Form: _________________________________


Name, Title (print) Signature
If additional space is required, please attach an addendum

This information can be disclosed only with written consent of the person to whom it pertains or is otherwise
CONFIDENTIAL permitted by such regulations (Uniform Health Information Act Title 70.02)

Mental Health Reauthorization Request - bhsMentalHealthReauthRequest Revised 20210615

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