Get Fax Completed Form To 866-834-7469 (ct)

Filling out the Fax Completed Form To 866-834-7469 (CT) is an important step in managing patient treatment reports efficiently. This guide will provide you with clear and concise instructions to help you complete the form accurately and ensure your submission is successful.

Follow the steps to fill out the form correctly and efficiently.

1. Press the ‘Get Form’ button to obtain the form and open it in your designated online editor.
2. Begin by filling in the "Patient" section with the patient's name and identification number (ID #). Ensure that all information is printed clearly.
3. Move on to the "Provider" section where you will enter the individual or group provider’s name, tax ID number, address, city, state, and the license number.
4. In the "ICD-9 Diagnosis" section, provide the appropriate numeric codes along with the descriptions for the patient's diagnosis. This section is crucial for accurate medical records.
5. Fill in the "Medical Conditions" checkbox as applicable to the patient’s history, highlighting any chronic issues that the patient faces.
6. In the "Current Risk Assessment" section, indicate any thoughts of self-harm or harm towards others by checking the relevant boxes.
7. List all medications in the "Medications" section, specifying the intent and plan for each medication. It's important to document any psychiatric or medical medications.
8. If there is coordination of care, note down interaction with other healthcare providers in the "Coordination of Care" section, including inpatient and outpatient details.
9. In the "Symptoms and Functional Impairment" section, check the degrees of severity for each symptom that is present.
10. If substance abuse is a concern, complete that section with specifics on substance choice, amount, frequency, and last use date.
11. Outline the desired observable outcomes and ensure that the patient agrees with the treatment goals in the relevant section.
12. Lastly, input the provider’s continued treatment plan including modality, CPT code, frequency of sessions, and anticipated completion time.
13. Complete the treatment progress section regarding level of improvement and include the number of sessions provided.
14. Sign the form to confirm that you are providing the requested services, and ensure the date is also included.
15. Once all sections are completed, review the information for accuracy, then save your changes. You can download, print, or share the finalized form as needed.

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