Get 1 866 811 4422 Form

IDENTIFYING DATA Patient s Name TRICARE OUTPATIENT TREATMENT REPORT P. O. Box 551188 Jacksonville Fl 32255-1188 Fax 1-866-811-4422 FILL OUT COMPLETELY TO AVOID DELAYS DOB Sponsor PROVIDER INFORMATION Provider Name Phone Fax DSM-IV TR Diagnosis Axis I -. /. /. Date first seen Date last seen Anticipated of sessions to complete treatment TREATMENT REPORT Current Clinical Information Circle each. Scale 0 None 1 Mild 2 Moderate 3 Severe 4 Extreme Aggression 0 1 2 3 4 Impulsivity Alcohol /Substance Use Job / School Problems 0 1 2 3 4 Anxiety/Panic Mania Appetite Disturbance Medical Illness Attention/Concentration Memory Deficit in ADLs Relationship Problems 0 1 2 3 4 Delusions Side Effects Depression Sleep Disturbance Hallucinations Weight Loss Other Discharge Goals Complete Remission Significant Improvement Baseline / Maintenance Medications Optional for Non-Physicians TYPE OF TREATMENT Behavior Modification Client Centered Cognitive-Behavioral Dialectical Behavioral Therapy Educational Existential/Humanistic Exposure/Response Prevention Family Therapy Gestalt Reality Therapy Group Therapy Relaxation Techniques Hypnosis Social Skills Training Interpersonal Supportive Medication Management Systematic Desensitization Parent Training Transactional Analysis Psychodynamic Psychotherapy Rational Emotive REQUESTED SERVICES CPT Code Frequency Provider s Signature Date Disclaimer Authorization indicates that ValueOptions-TRICARE has determined that medical necessity has been met for the requested service s but does not guarantee payment. Payment is contingent upon the beneficiary s eligibility and benefit limitations at the time services are rendered* 07/2005. /. /. Date first seen Date last seen Anticipated of sessions to complete treatment TREATMENT REPORT Current Clinical Information Circle each. Scale 0 None 1 Mild 2 Moderate 3 Severe 4 Extreme Aggression 0 1 2 3 4 Impulsivity Alcohol /Substance Use Job / School Problems 0 1 2 3 4 Anxiety/Panic Mania Appetite Disturbance Medical Illness Attention/Concentration Memory Deficit in ADLs Relationship Problems 0 1 2 3 4 Delusions Side Effects Depression Sleep Disturbance Hallucinations Weight Loss Other Discharge Goals Complete Remission Significant Improvement Baseline / Maintenance Medications Optional for Non-Physicians TYPE OF TREATMENT Behavior Modification Client Centered Cognitive-Behavioral Dialectical Behavioral Therapy Educational Existential/Humanistic Exposure/Response Prevention Family Therapy Gestalt Reality Therapy Group Therapy Relaxation Techniques Hypnosis Social Skills Training Interpersonal Supportive Medication Management Systematic Desensitization Parent Training Transactional Analysis Psychodynamic Psychotherapy Rational Emotive REQUESTED SERVICES CPT Code Frequency Provider s Signature Date Disclaimer Authorization indicates that ValueOptions-TRICARE has determined that medical necessity has been met for the requested service s but does not guarantee payment. Scale 0 None 1 Mild 2 Moderate 3 Severe 4 Extreme Aggression 0 1 2 3 4 Impulsivity Alcohol /Substance Use Job / School Problems 0 1 2 3 4 Anxiety/Panic Mania Appetite Disturbance Medical Illness Attention/Concentration Memory Deficit in ADLs Relationship Problems 0 1 2 3 4 Delusions Side Effects Depression Sleep Disturbance Hallucinations Weight Loss Other Discharge Goals Complete Remission Significant Improvement Baseline / Maintenance Medications Optional for Non-Physicians TYPE OF TREATMENT Behavior Modification Client Centered Cognitive-Behavioral Dialectical Behavioral Therapy Educational Existential/Humanistic Exposure/Response Prevention Family Therapy Gestalt Reality Therapy Group Therapy Relaxation Techniques Hypnosis Social Skills Training Interpersonal Supportive Medication Management Systematic Desensitization Parent Training Transactional Analysis Psychodynamic Psychotherapy Rational Emotive REQUESTED SERVICES CPT Code Frequency Provider s Signature Date Disclaimer Authorization indicates that ValueOptions-TRICARE has determined that medical necessity has been met for the requested service s but does not guarantee payment. Payment is contingent upon the beneficiary s eligibility and benefit limitations at the time services are rendered* 07/2005.