Get Behavioral Health Attending Provider Form

Completing the Behavioral Health Attending Provider Form is a crucial step in the process of applying for behavioral health support. This guide provides clear instructions to help users navigate the form easily and ensure accurate submission.

Follow the steps to complete the Behavioral Health Attending Provider Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, the patient should fill in their name at the top of Pages 2 and 3. They are also responsible for completing this section and ensuring that their attending physician fills out Sections 2 through 8.
3. Complete required information such as control number, gender, social security number, birth date, height, weight, home address, and mailing address if different. Check if the patient’s information is new, and fill in the employer details, including job title and occupation.
4. In Section 2, the attending physician is responsible for filling out information based on a recent examination. Ensure to attach any additional documentation necessary.
5. In the Impairing Diagnosis & Treatment section, the physician should indicate the primary impairing diagnosis and include DSM IV-TR multiaxial diagnosis along with appropriate ICD-9 codes.
6. Complete the symptom assessment that outlines the patient's absence from work due to disability. This includes specifying dates and detailing subjective symptoms, objective findings, interpersonal and work stressors.
7. Provide treatment details, including medications, their effects, hospitalization history, and compliance with treatment goals, frequency, and upcoming appointments.
8. In the History section, indicate if the patient has previously had the same condition, employment-related injury affidavit, and details of other treating professionals.
9. Outline the patient's current abilities and limitations while checking the corresponding responses about job functions. Enter objective findings and any psychological or medical restrictions in this section.
10. The attending physician must fill out their information, including name, degree, specialty, contact information, and provide their signature along with the date.
11. Ensure to review all entered information before finalizing. Once complete, users can save changes, download, print, or share the form as necessary.

Complete your Behavioral Health Attending Provider Form online today.