Get Dhmh Maryland Healthchoice Outpatient Review Form

Completing the Dhmh Maryland Healthchoice Outpatient Review Form online is an essential task for healthcare providers seeking to deliver services to clients in need of substance abuse treatment. This guide provides a clear, step-by-step approach to ensure that you accurately fill out each section of the form and comply with necessary requirements.

Follow the steps to complete the Dhmh Maryland Healthchoice Outpatient Review Form online.

1. Click ‘Get Form’ button to acquire the Dhmh Maryland Healthchoice Outpatient Review Form and open it in your online editor.
2. Begin by selecting the level of care appropriate for the client in Field 1, ensuring this aligns with the treatment being provided.
3. In Field 2, enter the name of the Managed Care Organization (MCO) and the date you are submitting the form. This helps in processing the request efficiently.
4. Fill in the client's full name in Field 3 as it appears on their Medical Assistance card.
5. Input the client’s date of birth in Field 4 to further confirm their identity.
6. In Field 5, mark the client’s gender, ensuring you select the option that accurately reflects their identity.
7. Enter the 11-digit Maryland Medical Assistance (MA) number in Field 6, found on the client’s Medical Assistance card.
8. Provide the client’s unique MCO number in Field 7, if applicable, or note 'N/A' if not available.
9. In Field 8, input the other insurance group number, if the client has additional coverage.
10. Fill out the client’s complete address in Field 9. If the client is homeless, indicate 'Homeless' in this field.
11. Enter the client’s phone number in Field 10. If they do not have a phone, write 'No Phone'.
12. In Field 11, specify the name, address, phone, and fax number of the treatment facility where the client is receiving care.
13. Complete Fields 12 and 13 with the Maryland Medicaid provider number and the Federal Tax ID number for the treatment facility.
14. Provide the name of the primary care physician in Field 14 if known, or denote 'N/A' otherwise.
15. Detail the treatment start date in Field 15, which may precede the date of MCO notification.
16. Indicate the requested start date for MCO coverage in Field 16.
17. If the client is pregnant, enter 'Yes' or 'No' in Field 17 and include the due date if known.
18. In Field 18, name the substances the client is abusing and complete the severity, frequency, and method fields using SMART language.
19. Provide the prior substance abuse treatment history in Field 19, including relevant details for the past three years.
20. List all current medications in Field 20, detailing adherence behaviors.
21. Complete the diagnosis using DSM IV codes in Field 21.
22. Circle the level of risk per the ASAM PPC in Field 22.
23. Request the treatment in Field 23 tailored to the client’s stated needs.
24. Provide an anticipated discharge date if known in Field 24.
25. Include any comments regarding treatment in Field 25 to support your submission.
26. Conclude by entering the treatment clinician's name, credentials, date, email, and phone number in the final section.
27. Once all fields are accurately completed, save your changes, download a copy of the form, or print it for sharing.

Complete your Dhmh Maryland Healthchoice Outpatient Review Form online now to ensure timely service coordination.