Get Otr Form

Filling out the Otr Form online is a straightforward process that allows users to efficiently request authorization for outpatient services. This guide will walk you through each section of the form to ensure that you provide all necessary information.

Follow the steps to complete the Otr Form effectively.

1. Click the ‘Get Form’ button to access the form and open it in a suitable editing tool.
2. Begin by entering the member's first and last name, along with their date of birth in the designated fields.
3. Provide the member's medical group, IPA, or health plan name, as well as their insurance ID number.
4. Fill in the requesting provider's name and credentials, followed by the PsycHealth, Ltd. provider ID number and phone number.
5. Document the previous PsycHealth, Ltd. referral number if applicable.
6. Ensure coordination of care by noting the member’s Primary Care Physician (PCP). Indicate whether the requesting provider has contacted the PCP to coordinate integrated care.
7. Record the date of contact with the PCP as well as the first date the member was contacted and the scheduled date for the initial session.
8. Document the actual date of the initial session (if different) and the most recent session date.
9. Enter the total number of sessions the member has attended to date.
10. Provide the diagnosis along with the corresponding DSM-IV code.
11. Describe the symptoms experienced by the member in detail.
12. Outline objective and measurable goals related to the member's treatment.
13. Detail the treatment plan and the progress made thus far.
14. List all medications that the member is currently taking, including dosage information.
15. Sign and date the form in the designated section before submission.
16. After completing the form, you may save any changes, download, print, or share the form as needed.

Take action now and efficiently complete the Otr Form online.