Get Psychiatric Inpatient (extended) Request Form.fm - Tmhp.com

This guide provides a clear and comprehensive approach to filling out the Psychiatric Inpatient (Extended) Request Form online. Follow these structured steps to ensure accurate completion of each section to facilitate the request process.

Follow the steps to accurately fill out your request form.

1. Click the ‘Get Form’ button to obtain the request form and open it in the online editor.
2. Begin by entering the identifying information. Fill in the Medicaid number, last name, date of birth, first name, middle initial, age, sex, date of admission, facility name, commitment type (if applicable), provider number, and effective date. Ensure all information is accurate and up to date.
3. In section IIA, describe the current status of primary symptoms that require continued acute hospital care. Include the date of the most recent occurrence, frequency, duration, and severity of the symptoms.
4. For section IIB, provide other relevant clinical or diagnostic information about the patient from the past 72 hours. This may require attaching additional pages or documents if necessary.
5. Complete section IIC by listing current psychiatric medications being taken by the patient, including the total daily dose for each medication.
6. In section IID, outline the discharge criteria, providing at least three specific criteria that the patient needs to meet for discharge.
7. Section IIE requires a description of treatment, contacts, and plans with family, school, or other relevant entities, including the intended outcomes of these interactions.
8. Provide the current diagnosis in section III (Axis I), and any additional diagnoses in section IV (Axis I and Axis II).
9. In section V, list the current functional assessment scores according to DSM IV, ensuring any relevant scales are accurately described.
10. Enter the number of hospital days requested in section VI, along with the projected discharge date. Fill in the specific dates as required in this section.
11. For section VII, outline the aftercare plan, including the provider or facility, frequency of follow-up, and the signature of the attending MD. Ensure to print their name, date, provider number, and license number.
12. Once you have completed all sections, review the form for accuracy. You can then save your changes, download a copy, print it, or share it as required.

Complete your Psychiatric Inpatient (Extended) Request Form online to facilitate your request efficiently.