Get Outpatient Treatment Request Otr Pdf - Celticare Health

Filling out the Outpatient Treatment Request OTR PDF - Celticare Health can be a straightforward process when approached step by step. This guide is designed to help users understand each section of the form clearly and efficiently.

Follow the steps to complete your outpatient treatment request form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Start by entering the date at the top of the form where indicated.
3. Fill out the provider information section, including provider name, tax ID number, NPI number, phone, and fax number.
4. Next, complete the member information section with the individual's name, date of birth, member ID number, phone, and fax.
5. Indicate if contact has occurred with the primary care provider (PCP) by checking the appropriate box.
6. Provide the DSM-IV TR diagnosis by filling out the applicable axes. If unsure, consult with the diagnosing provider.
7. Enter the dates when the member was first and last seen by the provider or agency.
8. Respond to the functional outcomes questions based on a recent face-to-face interview. Select the appropriate answers (Yes/No) and the level of impact.
9. Document the therapeutic approach or evidence-based treatment being used for this case.
10. Indicate the level of improvement observed to date, such as minor, moderate, major, or no progress.
11. Identify any barriers to discharge that might affect treatment plans.
12. Complete the symptom assessment section, checking off the degree to which symptoms impact daily living.
13. Perform a risk assessment by noting any suicidal or homicidal ideation and indicate if a safety plan is in place.
14. Outline the current measurable treatment goals and requested authorization details, including service type, frequency, intensity, start and anticipated completion dates.
15. Specify any additional codes requested for authorization if applicable.
16. Detail if traditional behavioral health services were attempted and provide additional relevant information if necessary.
17. Upon completing the form, review all entries for accuracy. Save changes, then download, print, or share the form as needed.

Complete your Outpatient Treatment Request OTR PDF - Celticare Health online today.