Get Mdwise Otr Form

Filling out the Mdwise Otr Form online can simplify the process of requesting outpatient treatment services. This guide will provide you with clear, step-by-step instructions to help you complete each section of the form accurately and efficiently.

Follow the steps to successfully complete the Mdwise Otr Form online:

1. Press the ‘Get Form’ button to retrieve the Mdwise Otr Form and open it in your preferred editor.
2. Begin by clearly entering the patient name in the designated field at the top of the form.
3. In the provider information section, check the appropriate box to indicate whether the requested services should be authorized to a specific provider or agency. Fill in the health plan name.
4. Provide the provider's name, date of birth, social security number, patient ID number, and their physical address, including street, city, state, and zip code.
5. Complete the last authorization number and include a phone number and fax number for the provider.
6. In the member information section, indicate the professional credential of the provider, such as MD, PhD, or other relevant titles, along with group/agency name, Medicaid/TPI/NPI number, and tax ID number.
7. If applicable, detail any previous behavioral health or substance abuse treatment including the names and dates of those treatments.
8. In the substance abuse section, specify if there is any history of substance use along with details like the substances used, amounts, frequency, and when last used.
9. Complete the DSM IV axis sections AXIS I through AXIS V as needed, identifying any mental health diagnoses.
10. Outline treatment goals by listing the primary complaint or problem to be addressed in treatment.
11. Describe objective discharge criteria to outline how readiness for discontinuation of treatment will be assessed.
12. Respond to the yes/no questions regarding the member’s family/support involvement in treatment and the primary medical physician communication.
13. Document the name of the primary medical physician and the date they were last notified, providing explanations for any 'No' answers if necessary.
14. In the requested authorization section, indicate the services requested and the total sessions needed, including relevant CPT codes.
15. Complete the overall progress and compliance ratings regarding treatment goals.
16. Provide the requested start date for authorization and details about any medical psychiatric evaluations done.
17. Finalize the form by having the provider sign and date it at the bottom. Ensure all information is clearly legible.
18. Once completed, save any changes made, and choose to download, print, or share the completed form as necessary.

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